Provider Demographics
NPI:1083822878
Name:FORD, AMY J (MS, RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:J
Last Name:FORD
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5026 MARATHON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4713
Mailing Address - Country:US
Mailing Address - Phone:608-469-5245
Mailing Address - Fax:
Practice Address - Street 1:5026 MARATHON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4713
Practice Address - Country:US
Practice Address - Phone:608-469-5245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1482-029133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric