Provider Demographics
NPI:1043837685
Name:AMENT, AMANDA (RDN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AMENT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MARLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:1090 W PARK PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-215-2005
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD813133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD813OtherLICENSE