Provider Demographics
NPI:1033638952
Name:HANNEKE, AMY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HANNEKE
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:164 S. 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254
Mailing Address - Country:US
Mailing Address - Phone:208-847-1630
Mailing Address - Fax:
Practice Address - Street 1:320 ASHLAND ST.
Practice Address - Street 2:APT. 1
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-8327
Practice Address - Country:US
Practice Address - Phone:314-591-6429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2018-03-20
Deactivation Date:2018-03-07
Deactivation Code:
Reactivation Date:2018-03-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered