MEDICARE: AMANDA THOMAS RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian
2	133VN1004X	Pediatric Nutrition Registered Dietitian
3	133VN1101X	Gerontological Nutrition Registered Dietitian
4	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian	86092027	CA

General Provider Information

NPI Number	:	1275159469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA THOMAS RD

Provider Business Mailing Address
First Line	:	2043 COLINA GRANDE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-3591
Country	:	US
Telephone Number	:	619-212-0028
Fax Number	:

Provider Business Practice Location Address
First Line	:	2043 COLINA GRANDE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92019-3591
Country	:	US
Telephone Number	:	619-212-0028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/23/2020

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