=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396507125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA STEPHENS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2024
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2115 STEPHENS PL STE 400B
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78130-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-439-1714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2262 HIDDEN MDW
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78130-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-665-2740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | DT84342
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------