Provider Demographics
NPI:1699394254
Name:MARTINEZ, STEPHANIE (RD, LD, IBCLC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RD, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 AIDIN ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-3404
Mailing Address - Country:US
Mailing Address - Phone:956-337-0237
Mailing Address - Fax:
Practice Address - Street 1:1620 MCCLELLAND AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-4630
Practice Address - Country:US
Practice Address - Phone:956-337-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2023-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-308307174N00000X
TXDT86318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN