Healthcare Provider Details

I. General information

NPI: 1518109289
Provider Name (Legal Business Name): AMY ELIZABETH LYKES RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 E PALMER ST
PHILADELPHIA PA
19125-4220
US

IV. Provider business mailing address

1107 E PALMER ST
PHILADELPHIA PA
19125-4220
US

V. Phone/Fax

Practice location:
  • Phone: 732-822-0451
  • Fax: 609-581-7726
Mailing address:
  • Phone: 732-822-0451
  • Fax: 609-228-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number953465
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: