Provider Demographics
NPI:1992483242
Name:MARTINEZ, MINDY (RD)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:MARTINEZ
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 1:145 NEW BERN ST APT 458
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-4321
Mailing Address - Country:US
Mailing Address - Phone:520-243-0190
Mailing Address - Fax:
Practice Address - Street 1:10400 MALLARD CREEK RD STE 340
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5203
Practice Address - Country:US
Practice Address - Phone:520-243-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered