Provider Demographics
NPI:1659857688
Name:O'LEARY, AMY (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:O'LEARY
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 1:100 WOODRUFF CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WOODRUFF CIR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0005
Practice Address - Country:US
Practice Address - Phone:703-585-5787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4446133V00000X
390200000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program