Provider Demographics
NPI:1083939185
Name:BORK, AMY (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BORK
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 1:4000 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-5640
Mailing Address - Country:US
Mailing Address - Phone:319-236-0580
Mailing Address - Fax:
Practice Address - Street 1:4000 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5640
Practice Address - Country:US
Practice Address - Phone:319-236-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002125133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered