MEDICARE: AMANDA BOOSTROM RDN

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

General Provider Information

NPI Number	:	1578900684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA BOOSTROM RDN

Provider Business Mailing Address
First Line	:	4513 WILLET DR
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-3944
Country	:	US
Telephone Number	:	703-831-2125
Fax Number	:

Provider Business Practice Location Address
First Line	:	4513 WILLET DR
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-3944
Country	:	US
Telephone Number	:	703-831-2125
Fax Number	:

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

Provider Enumeration Date	:	05/30/2013
Last Update Date	:	07/21/2022

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Directions to “ AMANDA BOOSTROM RDN” Practice Location

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