Provider Demographics
NPI:1518001122
Name:FOX, AMY M (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:FOX
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3100 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3866
Practice Address - Country:US
Practice Address - Phone:916-774-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA718750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM593XMedicare PIN
CA718750Medicare PIN
CAP79432Medicare UPIN
CABM593YMedicare PIN
CAZZZ25241ZMedicare ID - Type Unspecified