Provider Demographics
NPI:1619432432
Name:MARTINEZ, MARISSA MARIE (MS, RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 S FLORES ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1219
Mailing Address - Country:US
Mailing Address - Phone:855-481-1149
Mailing Address - Fax:
Practice Address - Street 1:646 S FLORES ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78204-1219
Practice Address - Country:US
Practice Address - Phone:855-481-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86050978133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered