Provider Demographics
NPI:1548790736
Name:GRUPE, AMANDA LYNN (RD, LD, CSR)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:GRUPE
Suffix:
Gender:F
Credentials:RD, LD, CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 SEMINARY RD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:OH
Mailing Address - Zip Code:44846-9476
Mailing Address - Country:US
Mailing Address - Phone:520-510-8217
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839-1647
Practice Address - Country:US
Practice Address - Phone:419-602-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI929935133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered