Healthcare Provider Details

I. General information

NPI: 1780548479
Provider Name (Legal Business Name): AMANDA LIDSTER RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 SUMMIT RUN
LEWISVILLE TX
75077-2931
US

IV. Provider business mailing address

717 SUMMIT RUN
LEWISVILLE TX
75077-2931
US

V. Phone/Fax

Practice location:
  • Phone: 940-453-7239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT83875
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: