Healthcare Provider Details

I. General information

NPI: 1811656960
Provider Name (Legal Business Name): AMELIA J BAKER RDN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST
PORTLAND ME
04102-3100
US

IV. Provider business mailing address

887 CONGRESS ST
PORTLAND ME
04102-3100
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5690
  • Fax:
Mailing address:
  • Phone: 207-662-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDI1687
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: