Provider Demographics
NPI:1992993869
Name:MARTINEZ, TERESA MARIE (RD, CD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W 200 S
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-3205
Mailing Address - Country:US
Mailing Address - Phone:435-650-9455
Mailing Address - Fax:
Practice Address - Street 1:28 S 100 E
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3002
Practice Address - Country:US
Practice Address - Phone:435-637-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5748433-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6545 999000021033Medicaid