Provider Demographics
NPI:1639460561
Name:MARTIN, AMBER DAWN (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:DAWN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N HERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:KS
Mailing Address - Zip Code:67420-2320
Mailing Address - Country:US
Mailing Address - Phone:785-534-0010
Mailing Address - Fax:
Practice Address - Street 1:605 N HERSEY AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420-2320
Practice Address - Country:US
Practice Address - Phone:785-534-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1544133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered