Healthcare Provider Details

I. General information

NPI: 1477148666
Provider Name (Legal Business Name): AMANDA NELSON RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA GHEEN

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4626 N 300 W STE 150
PROVO UT
84604-6077
US

IV. Provider business mailing address

4626 N 300 W STE 150
PROVO UT
84604-6077
US

V. Phone/Fax

Practice location:
  • Phone: 801-407-4134
  • Fax: 801-877-0864
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number40589-DI-0
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86175855
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: