Healthcare Provider Details

I. General information

NPI: 1386929164
Provider Name (Legal Business Name): AMBER MIZUKI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DRIVE BLDG 116
HAMPTON VA
23667
US

IV. Provider business mailing address

100 EMANCIPATION DRIVE BLDG 116
HAMPTON VA
23667
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 757-722-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01000859
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: