Provider Demographics
NPI:1407664220
Name:MARTIN, KAITLIN (RD)
Entity type:Individual
Prefix:
First Name:KAITLIN
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 1:2129 ROLLING HILL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3736
Mailing Address - Country:US
Mailing Address - Phone:806-678-8605
Mailing Address - Fax:
Practice Address - Street 1:2129 ROLLING HILL RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3736
Practice Address - Country:US
Practice Address - Phone:806-678-8605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85469133V00000X
NCL006341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered