Healthcare Provider Details

I. General information

NPI: 1972470037
Provider Name (Legal Business Name): AMANDA BUSTAMANTE RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 ALAMEDA AVE
EL PASO TX
79905-2705
US

IV. Provider business mailing address

311 AMELIA DR
EL PASO TX
79912-4831
US

V. Phone/Fax

Practice location:
  • Phone: 915-298-5444
  • Fax:
Mailing address:
  • Phone: 915-346-7647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT84792
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: