Healthcare Provider Details

I. General information

NPI: 1952517955
Provider Name (Legal Business Name): LISA WILSON MARTIN RD, MS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 GALLERIA AVENUE
RALEIGH NC
27614
US

IV. Provider business mailing address

211 FRIDAY CENTER DR SUITE 2091, ROOM 2094 HEDRICK BUILDING
CHAPEL HILL NC
27517-9499
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-1511
  • Fax: 919-570-7751
Mailing address:
  • Phone: 984-974-1191
  • Fax: 984-974-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberL002570
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL002570
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: