Healthcare Provider Details

I. General information

NPI: 1417674219
Provider Name (Legal Business Name): AMANDA ELLISTON LDN, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 GLENN DR
WILBRAHAM MA
01095-1404
US

IV. Provider business mailing address

12 GLENN DR
WILBRAHAM MA
01095-1404
US

V. Phone/Fax

Practice location:
  • Phone: 413-695-2884
  • Fax:
Mailing address:
  • Phone: 413-695-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number3157
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number20983
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: