Provider Demographics
NPI:1033597323
Name:CARSON, AMY (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RUTH
Other - Last Name:SILVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1114 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1002
Mailing Address - Country:US
Mailing Address - Phone:708-383-1114
Mailing Address - Fax:
Practice Address - Street 1:1114 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1002
Practice Address - Country:US
Practice Address - Phone:708-383-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006342133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered