Provider Demographics
NPI:1801035423
Name:HENRY, IRENE (RD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:HENRY
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 1:1170 TRAILSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-2185
Mailing Address - Country:US
Mailing Address - Phone:707-292-0791
Mailing Address - Fax:
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:925-295-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA923548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered