Healthcare Provider Details

I. General information

NPI: 1003339458
Provider Name (Legal Business Name): AMY MARSHALL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARY ST
EVANSVILLE IN
47710-1658
US

IV. Provider business mailing address

3348 FIVE DOLLAR RD
EVANSVILLE IN
47720-8952
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-3493
  • Fax:
Mailing address:
  • Phone: 812-454-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002491A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: