Provider Demographics
NPI:1083810881
Name:CRIST, AMY MARIE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:CRIST
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 OLYMPIA WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9072
Mailing Address - Country:US
Mailing Address - Phone:502-570-3797
Mailing Address - Fax:
Practice Address - Street 1:1140 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9330
Practice Address - Country:US
Practice Address - Phone:502-570-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered