Provider Demographics
NPI:1447741087
Name:MEDINA, IRMA I (RDN)
Entity Type:Individual
Prefix:MRS
First Name:IRMA
Middle Name:I
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50745
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76206-0745
Mailing Address - Country:US
Mailing Address - Phone:855-383-1240
Mailing Address - Fax:855-383-1241
Practice Address - Street 1:2800 SHORELINE DR STE 120
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-0130
Practice Address - Country:US
Practice Address - Phone:855-383-1240
Practice Address - Fax:855-383-1241
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered