Provider Demographics
NPI:1235728395
Name:SHEAFFER, AMANDA SHEAFFER
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHEAFFER
Last Name:SHEAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W ADAMS ST UNIT 375
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3090
Mailing Address - Country:US
Mailing Address - Phone:847-609-9101
Mailing Address - Fax:
Practice Address - Street 1:625 W ADAMS ST
Practice Address - Street 2:WEWROK 20-144
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661
Practice Address - Country:US
Practice Address - Phone:847-609-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86093797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered