Healthcare Provider Details

I. General information

NPI: 1124964424
Provider Name (Legal Business Name): AMANDA WIDMAR RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S DOBSON RD STE 107
MESA AZ
85202-4769
US

IV. Provider business mailing address

255 S KYRENE RD UNIT 133
CHANDLER AZ
85226-4490
US

V. Phone/Fax

Practice location:
  • Phone: 480-681-4453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: