Provider Demographics
NPI:1376756189
Name:KUCKARTZ, AMANDA ANNE (RD, CD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:KUCKARTZ
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18051 RIVER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7091
Mailing Address - Country:US
Mailing Address - Phone:317-773-0002
Mailing Address - Fax:317-776-6095
Practice Address - Street 1:18051 RIVER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7091
Practice Address - Country:US
Practice Address - Phone:317-773-0002
Practice Address - Fax:317-776-6095
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001622A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150900DDMedicare PIN
IN151660BBMedicare PIN
IN151540HHMedicare PIN
IN255310AMedicare PIN
IN151560MMMedicare PIN
IN151550CCMedicare PIN