Healthcare Provider Details

I. General information

NPI: 1205170263
Provider Name (Legal Business Name): AMY SWART WILKE MS RD CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

827 N HOLLYWOOD WAY # 180
BURBANK CA
91505-2814
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax:
Mailing address:
  • Phone: 818-885-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number717544
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: