Provider Demographics
NPI:1780928804
Name:MARTINE, TARA LYNN (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:MARTINE
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:FLINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:728 EVERETTS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9364
Mailing Address - Country:US
Mailing Address - Phone:910-409-3996
Mailing Address - Fax:
Practice Address - Street 1:7215 OGDEN BUSINESS LN
Practice Address - Street 2:UNIT 106
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-7375
Practice Address - Country:US
Practice Address - Phone:910-409-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003743133N00000X
NC1018821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist