Provider Demographics
NPI:1598107112
Name:DAVIS, AMANDA (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 RED MILE TRL
Mailing Address - Street 2:APT J
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7343
Mailing Address - Country:US
Mailing Address - Phone:270-348-6779
Mailing Address - Fax:
Practice Address - Street 1:309 11TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-1435
Practice Address - Country:US
Practice Address - Phone:502-732-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1108516133V00000X
KY2459133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered