Healthcare Provider Details

I. General information

NPI: 1710252440
Provider Name (Legal Business Name): AMANDA CAROLE BRATTON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ SUITE 1203
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

3165 MOSS POINTE DR
SAINT CHARLES MO
63303-6551
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-7733
  • Fax:
Mailing address:
  • Phone: 314-952-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number2009022863
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: