Provider Demographics
NPI:1467215467
Name:SAN, AMY (RDN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SECRETARIAT DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-3301
Mailing Address - Country:US
Mailing Address - Phone:314-498-6961
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-7833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022031990133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered