Healthcare Provider Details

I. General information

NPI: 1649281775
Provider Name (Legal Business Name): AMY HAGER RDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2841 LUMP GULCH RD
BLACK HAWK CO
80422-4314
US

IV. Provider business mailing address

2841 LUMP GULCH RD
BLACK HAWK CO
80422-4314
US

V. Phone/Fax

Practice location:
  • Phone: 919-272-7350
  • Fax:
Mailing address:
  • Phone: 919-272-7350
  • Fax: 720-770-5459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL002567
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: