Provider Demographics
NPI:1972185411
Name:IRVINE, ALEXIS JEAN (RDN)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JEAN
Last Name:IRVINE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WILCOX MNR
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1813
Mailing Address - Country:US
Mailing Address - Phone:860-884-3407
Mailing Address - Fax:
Practice Address - Street 1:10 WILCOX MNR
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1813
Practice Address - Country:US
Practice Address - Phone:860-884-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001932133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered