Provider Demographics
NPI:1184310344
Name:MARTIN, ALLISON JEAN (RD, LD, CPT)
Entity type:Individual
Prefix:MRS
First Name:ALLISON
Middle Name:JEAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD, LD, CPT
Other - Prefix:MRS
Other - First Name:ALLISON
Other - Middle Name:JEAN
Other - Last Name:BOUSHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 S ALCO AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2036
Mailing Address - Country:US
Mailing Address - Phone:803-414-2142
Mailing Address - Fax:
Practice Address - Street 1:410 S ALCO AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2036
Practice Address - Country:US
Practice Address - Phone:803-414-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered