Provider Demographics
NPI:1225577208
Name:BLAKE, AMANDA (MS, RD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2592 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3736
Mailing Address - Country:US
Mailing Address - Phone:805-404-0155
Mailing Address - Fax:
Practice Address - Street 1:2592 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065
Practice Address - Country:US
Practice Address - Phone:805-404-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARD86027382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered