Provider Demographics
NPI:1851968374
Name:MARTIN, THERESA A (RDN, LMNT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDN, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-6441
Mailing Address - Country:US
Mailing Address - Phone:712-325-1990
Mailing Address - Fax:
Practice Address - Street 1:902 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-6441
Practice Address - Country:US
Practice Address - Phone:712-325-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA106187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered