Provider Demographics
NPI:1548584188
Name:WARDELL, AMY T (RD LDN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:T
Last Name:WARDELL
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2325
Mailing Address - Fax:413-582-2804
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2325
Practice Address - Fax:413-582-2804
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2351133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWA MT0788Medicare PIN