Provider Demographics
NPI:1275264194
Name:MILLER, AMANDA RAE (RDN, LRD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RDN, LRD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RAE
Other - Last Name:YANVARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-1564
Mailing Address - Country:US
Mailing Address - Phone:480-294-6543
Mailing Address - Fax:480-294-6544
Practice Address - Street 1:1237 S VAL VISTA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6401
Practice Address - Country:US
Practice Address - Phone:480-294-6543
Practice Address - Fax:480-294-6544
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0834133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered