Provider Demographics
NPI:1063731057
Name:MARTIN, LYNNE (RD)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 4TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3310
Mailing Address - Country:US
Mailing Address - Phone:415-505-2387
Mailing Address - Fax:
Practice Address - Street 1:523 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3310
Practice Address - Country:US
Practice Address - Phone:415-505-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA953786133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered