MEDICARE: AMY SANFORD 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	1432-029	WI

General Provider Information

NPI Number	:	1598126583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY SANFORD RD

Provider Business Mailing Address
First Line	:	W270N6845 WOODLAND OAKS DR
Second Line	:
City	:	SUSSEX
State	:	WI
Zip	:	53089-2343
Country	:	US
Telephone Number	:	262-370-3677
Fax Number	:

Provider Business Practice Location Address
First Line	:	W270N6845 WOODLAND OAKS DR
Second Line	:
City	:	SUSSEX
State	:	WI
Zip	:	53089-2343
Country	:	US
Telephone Number	:	262-370-3677
Fax Number	:

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

Provider Enumeration Date	:	03/17/2016
Last Update Date	:	03/17/2016

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