Healthcare Provider Details

I. General information

NPI: 1457936015
Provider Name (Legal Business Name): AMY JEAN ELDRIDGE RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY JEAN KING

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SMYTH RD
MANCHESTER NH
03104-7007
US

IV. Provider business mailing address

236 MEADOW RD
NEW BOSTON NH
03070-3818
US

V. Phone/Fax

Practice location:
  • Phone: 603-854-9181
  • Fax:
Mailing address:
  • Phone: 503-265-9396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5004
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1190
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: