Provider Demographics
NPI:1114393170
Name:LIRA, IVORY (RDN)
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:LIRA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:IVORY
Other - Middle Name:
Other - Last Name:MICELI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15195 HEATHCOTE BLVD STE 330
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169
Practice Address - Country:US
Practice Address - Phone:571-284-3380
Practice Address - Fax:571-284-3389
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101206133V00000X
VA86049472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered