Healthcare Provider Details

I. General information

NPI: 1013562271
Provider Name (Legal Business Name): AMELIA TI MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W KINGSBRIDGE RD RM 1C-328
BRONX NY
10468-3904
US

IV. Provider business mailing address

66 SAINT NICHOLAS AVE APT 4D
NEW YORK NY
10026-2956
US

V. Phone/Fax

Practice location:
  • Phone: 718-584-9000
  • Fax:
Mailing address:
  • Phone: 408-505-2363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86054552
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: