Provider Demographics
NPI:1770830382
Name:BYRD, MAMIE W (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:W
Last Name:BYRD
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ARIEL CT
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-4433
Mailing Address - Country:US
Mailing Address - Phone:919-550-5674
Mailing Address - Fax:
Practice Address - Street 1:15 NOBLE ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9300
Practice Address - Country:US
Practice Address - Phone:919-322-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003168133V00000X
DCD1273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered