Provider Demographics
NPI:1518109289
Name:LYKES, AMY ELIZABETH (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:LYKES
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E PALMER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-4220
Mailing Address - Country:US
Mailing Address - Phone:732-822-0451
Mailing Address - Fax:609-228-5450
Practice Address - Street 1:1107 E PALMER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4220
Practice Address - Country:US
Practice Address - Phone:732-822-0451
Practice Address - Fax:609-581-7726
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ953465133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ155560Medicaid