Healthcare Provider Details

I. General information

NPI: 1528979713
Provider Name (Legal Business Name): IVY MENDHEIM FAUNTLEROY RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 GREENBRIER BLVD STE 105
COVINGTON LA
70433-7237
US

IV. Provider business mailing address

73561 HIGHWAY 437
COVINGTON LA
70435-6159
US

V. Phone/Fax

Practice location:
  • Phone: 985-789-3341
  • Fax:
Mailing address:
  • Phone: 985-789-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4284
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: