Provider Demographics
NPI:1497202592
Name:LUNGREN, AMANDA (RDN, CD)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:LUNGREN
Suffix:
Gender:F
Credentials:RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 NE 165TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-6126
Mailing Address - Country:US
Mailing Address - Phone:702-612-6928
Mailing Address - Fax:
Practice Address - Street 1:2505 NE 165TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-6126
Practice Address - Country:US
Practice Address - Phone:702-612-6928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60686510133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered