Provider Demographics
NPI:1831605393
Name:LA GRECA, MANDANA (DCN, CNS)
Entity type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:LA GRECA
Suffix:
Gender:F
Credentials:DCN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13008 HINDCROSS DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15815 DELANCEY LN
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5910
Practice Address - Country:US
Practice Address - Phone:704-794-7329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5227133NN1002X
133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education