Provider Demographics
NPI:1699040501
Name:MENTRIKOSKI, AMY L (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MENTRIKOSKI
Suffix:
Gender:F
Credentials:RD
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 239
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0239
Mailing Address - Country:US
Mailing Address - Phone:540-932-5508
Mailing Address - Fax:
Practice Address - Street 1:79 N MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2344
Practice Address - Country:US
Practice Address - Phone:540-932-5508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA85007146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered