Healthcare Provider Details

I. General information

NPI: 1881034056
Provider Name (Legal Business Name): AMANDA BREWSAUGH R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-5310
  • Fax:
Mailing address:
  • Phone: 937-641-5310
  • Fax: 203-688-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number001134
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1069423
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.7583
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: