Provider Demographics
NPI:1639508161
Name:ARCHIBALD, AMANDA (RD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 W RIDGES BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-1703
Mailing Address - Country:US
Mailing Address - Phone:301-865-4607
Mailing Address - Fax:
Practice Address - Street 1:361 W RIDGES BLVD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-1703
Practice Address - Country:US
Practice Address - Phone:301-865-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01520133N00000X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education