Healthcare Provider Details

I. General information

NPI: 1043757149
Provider Name (Legal Business Name): AMANDA SALLEY MS, RD, CSP, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 PALM COVE WAY
MOUNT PLEASANT SC
29466-8160
US

IV. Provider business mailing address

129 PALM COVE WAY
MOUNT PLEASANT SC
29466-8160
US

V. Phone/Fax

Practice location:
  • Phone: 260-804-2880
  • Fax:
Mailing address:
  • Phone: 260-804-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164.006966
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2758
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: