Healthcare Provider Details

I. General information

NPI: 1487925996
Provider Name (Legal Business Name): AMANDA NELSON MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 MILLER RD
GENEVA IL
60134-3996
US

IV. Provider business mailing address

2814 MILLER RD
GENEVA IL
60134-3996
US

V. Phone/Fax

Practice location:
  • Phone: 630-479-8786
  • Fax:
Mailing address:
  • Phone: 630-479-8786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164.005465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: