Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 6232 | TX |
NPI | 1083763437 |
---|---|
Provider Name | Michelle Martz |
First Address | Highland Village, TX 75077-7188 |
Second Address | Highland Village, TX 75077-7188 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
44998 | (02) | TX |