Provider Demographics
NPI:1508054131
Name:KING, AMY R (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:KING
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 1:163 BOSTON POST RD
Mailing Address - Street 2:SUITE 3&4
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2840
Mailing Address - Country:US
Mailing Address - Phone:860-444-8774
Mailing Address - Fax:860-444-8776
Practice Address - Street 1:163 BOSTON POST RD
Practice Address - Street 2:SUITE 3&4
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2840
Practice Address - Country:US
Practice Address - Phone:860-444-8774
Practice Address - Fax:860-444-8776
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000727133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered