Healthcare Provider Details

I. General information

NPI: 1417580614
Provider Name (Legal Business Name): AMY G WOODMAN RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2020
Last Update Date: 02/16/2020
Certification Date: 02/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SILVER BROOK LN
NORTH GRANBY CT
06060-1111
US

IV. Provider business mailing address

1 SILVER BROOK LANE
NORTH GRANBY CT
06060-1111
US

V. Phone/Fax

Practice location:
  • Phone: 860-324-8963
  • Fax:
Mailing address:
  • Phone: 860-324-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: