Provider Demographics
NPI:1285036962
Name:HUBBARD, AMANDA HENDERSON (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:HENDERSON
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 CLIMBING ROSE BLVD
Mailing Address - Street 2:APT L
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-4110
Mailing Address - Country:US
Mailing Address - Phone:803-374-7023
Mailing Address - Fax:
Practice Address - Street 1:611 CLIMBING ROSE BLVD
Practice Address - Street 2:APT L
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-4110
Practice Address - Country:US
Practice Address - Phone:803-374-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003929133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered