Healthcare Provider Details

I. General information

NPI: 1740179076
Provider Name (Legal Business Name): AMANDA KATE MULLANE MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH RD STE 120
FARMINGTON CT
06032-2483
US

IV. Provider business mailing address

5 OLDE FLATBROOK RD
EAST HAMPTON CT
06424-1607
US

V. Phone/Fax

Practice location:
  • Phone: 860-334-8902
  • Fax: 860-334-8902
Mailing address:
  • Phone: 860-334-8902
  • Fax: 860-837-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number001929
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: