Provider Demographics
NPI:1285756585
Name:LORENZO, MIRTA WLODINGUER (RD LD)
Entity type:Individual
Prefix:MRS
First Name:MIRTA
Middle Name:WLODINGUER
Last Name:LORENZO
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E PACES FERRY RD NE APT 233
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-2847
Mailing Address - Country:US
Mailing Address - Phone:404-332-1820
Mailing Address - Fax:
Practice Address - Street 1:3155 ROYAL DR # 125
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2430
Practice Address - Country:US
Practice Address - Phone:404-332-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD001583OtherLICENSE NO.