Basic Information
| Provider Information | |||||||||
| NPI: | 1013248475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOGAN | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | COMPLIANCE MC 2433 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537920001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086620817 | ||||||||
| FaxNumber: | 6082034544 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | COMPLIANCE MC 2433 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537920001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086620817 | ||||||||
| FaxNumber: | 6082034544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2010 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 337923 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 745-029 | 01 | WI | CERTIFIED DIETITIAN | OTHER |