Provider Demographics
NPI:1912374273
Name:MARTINO, MARISSA (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HARBOR POINTE DR
Mailing Address - Street 2:
Mailing Address - City:HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10927-2102
Mailing Address - Country:US
Mailing Address - Phone:610-506-8930
Mailing Address - Fax:
Practice Address - Street 1:18 HARBOR POINTE DR
Practice Address - Street 2:
Practice Address - City:HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10927
Practice Address - Country:US
Practice Address - Phone:610-506-8930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86013223133V00000X
PADN005713133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered