Provider Demographics
NPI:1083188411
Name:SMITH, AMBER (RD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:NOLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:412 S SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9702
Mailing Address - Country:US
Mailing Address - Phone:765-432-1759
Mailing Address - Fax:
Practice Address - Street 1:412 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9702
Practice Address - Country:US
Practice Address - Phone:260-358-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002470A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered