Healthcare Provider Details

I. General information

NPI: 1033638952
Provider Name (Legal Business Name): AMY HANNEKE RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY LEE RDN, LD

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date: 03/07/2018
Reactivation Date: 03/20/2018

III. Provider practice location address

320 ASHLAND ST. APT. 1
SODA SPRINGS ID
83276-8327
US

IV. Provider business mailing address

164 S. 5TH ST.
MONTPELIER ID
83254
US

V. Phone/Fax

Practice location:
  • Phone: 314-591-6429
  • Fax:
Mailing address:
  • Phone: 208-847-1630
  • 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: