Provider Demographics
NPI:1548223829
Name:EASLEY, AMBER L (RD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:EASLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:L
Other - Last Name:BULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1995 MILLER COUNTY 13
Mailing Address - Street 2:
Mailing Address - City:FOUKE
Mailing Address - State:AR
Mailing Address - Zip Code:71837-9298
Mailing Address - Country:US
Mailing Address - Phone:870-653-2383
Mailing Address - Fax:
Practice Address - Street 1:1000 PINE ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5100
Practice Address - Country:US
Practice Address - Phone:903-798-7260
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06802133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B8970Medicare UPIN