Healthcare Provider Details

I. General information

NPI: 1396133617
Provider Name (Legal Business Name): AMANDA BJORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JAKSHA

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BMEDDAC GEBAUDE 700 ROSE BARRACKS SUED LAGER
VILSECK BAYERN
92249
DE

IV. Provider business mailing address

CMR 415 BOX 3231
APO AE
09114-0033
US

V. Phone/Fax

Practice location:
  • Phone: 00499662833216
  • Fax:
Mailing address:
  • Phone: 004915140476256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI 60165277
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: