Healthcare Provider Details

I. General information

NPI: 1285462622
Provider Name (Legal Business Name): AMY ANDERSON REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 NW ARCADIA CT
BEAVERTON OR
97006-5608
US

IV. Provider business mailing address

1900 NW ARCADIA CT
BEAVERTON OR
97006-5608
US

V. Phone/Fax

Practice location:
  • Phone: 503-505-0495
  • Fax:
Mailing address:
  • Phone: 503-505-0495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86012258
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: