Provider Demographics
NPI:1336696459
Name:BRAGAGNINI, AMY M (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BRAGAGNINI
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 1:630 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:203-688-2422
Mailing Address - Fax:
Practice Address - Street 1:630 KENMOOR AVE SE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-600-4950
Practice Address - Fax:855-817-3028
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
886364133V00000X
CT1439133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02658OtherYNHH MEDICARE NUMBER