Provider Demographics
NPI:1104223833
Name:MARTIN, CHRISTINA CLARK (RDN)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:CLARK
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2102
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2102
Mailing Address - Country:US
Mailing Address - Phone:318-614-9516
Mailing Address - Fax:
Practice Address - Street 1:146 W OAK ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-3329
Practice Address - Country:US
Practice Address - Phone:318-614-9516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered