Provider Demographics
NPI:1417674219
Name:ELLISTON, AMANDA (LDN, CLC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLISTON
Suffix:
Gender:F
Credentials:LDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GLENN DR
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1404
Mailing Address - Country:US
Mailing Address - Phone:413-695-2884
Mailing Address - Fax:
Practice Address - Street 1:30 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2630
Practice Address - Country:US
Practice Address - Phone:413-533-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3157133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty