Provider Demographics
NPI:1962014530
Name:MARTIN, KELLY (BS, MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48346 LONG LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-4527
Mailing Address - Country:US
Mailing Address - Phone:610-952-7881
Mailing Address - Fax:
Practice Address - Street 1:225 TOWN SQUARE DR
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-6534
Practice Address - Country:US
Practice Address - Phone:610-952-7881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education