Provider Demographics
NPI:1336165869
Name:MARTIN, LISA W (RD/ CDE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD/ CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 MERSHAM CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8377
Mailing Address - Country:US
Mailing Address - Phone:704-548-0404
Mailing Address - Fax:
Practice Address - Street 1:2893 STURGIS RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-6607
Practice Address - Country:US
Practice Address - Phone:803-366-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL651262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8HC666Medicare ID - Type Unspecified