Basic Information
Provider Information | |||||||||
NPI: | 1407458284 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | WHITNEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPH, RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13081 GREENWOOD RD | ||||||||
Address2: |   | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 230591724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042126259 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 125 NATIONWIDE DR | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245024272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4342003908 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2020 | ||||||||
LastUpdateDate: | 11/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.