Basic Information
| Provider Information | |||||||||
| NPI: | 1164488243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTENS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTENS | ||||||||
| OtherFirstName: | SANDI | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7111 E 21ST ST N STE A | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672061078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166842851 | ||||||||
| FaxNumber: | 3166835239 | ||||||||
| Practice Location | |||||||||
| Address1: | 7111 E 21ST ST N STE A | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166842851 | ||||||||
| FaxNumber: | 3166835239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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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 | 000578 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 723310 | 01 | REGISTERED DIETITAN | OTHER |