Provider Demographics
NPI:1053956847
Name:MINCEMEYER, TORI ONITA (RD)
Entity type:Individual
Prefix:MRS
First Name:TORI
Middle Name:ONITA
Last Name:MINCEMEYER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:TORI
Other - Middle Name:ONITA
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:1615 BESSIE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5201
Mailing Address - Country:US
Mailing Address - Phone:573-517-8556
Mailing Address - Fax:
Practice Address - Street 1:2630 OLD ORCHARD RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3824
Practice Address - Country:US
Practice Address - Phone:573-517-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered