Provider Demographics
NPI:1811409121
Name:IRWIN, MANDI (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:IRWIN
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:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-0848
Mailing Address - Country:US
Mailing Address - Phone:336-753-6750
Mailing Address - Fax:336-751-0335
Practice Address - Street 1:210 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2039
Practice Address - Country:US
Practice Address - Phone:336-753-6750
Practice Address - Fax:336-751-0335
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered