Provider Demographics
NPI:1730440322
Name:MARTIN, MICHELE MARIE (RD)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:MICHELE
Other - Middle Name:MARIE
Other - Last Name:HARNESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1188
Mailing Address - Country:US
Mailing Address - Phone:618-997-5311
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005412133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered