Provider Demographics
NPI:1518383504
Name:MIRZAIE, MANDY (RD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MIRZAIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:SMITH
Other - Last Name:FOUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:12018 W BROAD ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7796
Mailing Address - Country:US
Mailing Address - Phone:804-360-0600
Mailing Address - Fax:804-360-0601
Practice Address - Street 1:12018 W BROAD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7796
Practice Address - Country:US
Practice Address - Phone:804-360-0600
Practice Address - Fax:804-360-0601
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered