Healthcare Provider Details

I. General information

NPI: 1376399733
Provider Name (Legal Business Name): CANDACE MARTELL MS, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WOODLAND KNOLLS RD
GERMANTOWN HILLS IL
61548-9429
US

IV. Provider business mailing address

595 PACIFIC AVE
SAN FRANCISCO CA
94133-4681
US

V. Phone/Fax

Practice location:
  • Phone: 815-954-8742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number164009704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: