Provider Demographics
NPI:1164934311
Name:BRANCH, AMY ELIZABETH (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:BRANCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:VANDEWIELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:317-944-3500
Practice Address - Fax:317-962-2474
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001952A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered