Provider Demographics
NPI:1003067422
Name:REILSON, AMANDA MARIE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:REILSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 MARINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JACOB
Mailing Address - State:IL
Mailing Address - Zip Code:62281-1243
Mailing Address - Country:US
Mailing Address - Phone:618-644-3129
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:618-391-5528
Practice Address - Fax:618-288-3638
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004969133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered