Healthcare Provider Details

I. General information

NPI: 1073284691
Provider Name (Legal Business Name): ANDREINA THIELEN MARTIN MPH, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD # 5891
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

725 WELCH RD # 5891
PALO ALTO CA
94304-1601
US

V. Phone/Fax

Practice location:
  • Phone: 650-736-8183
  • Fax: 650-736-2130
Mailing address:
  • Phone: 650-736-8183
  • Fax: 650-736-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86172254
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: