Provider Demographics
NPI:1710296256
Name:KUSSKE, AMANDA PRESTON (MS, RD, CSO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:PRESTON
Last Name:KUSSKE
Suffix:
Gender:F
Credentials:MS, RD, CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 RIVER STYX RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9782
Mailing Address - Country:US
Mailing Address - Phone:206-817-6586
Mailing Address - Fax:
Practice Address - Street 1:6060 RIVER STYX RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9782
Practice Address - Country:US
Practice Address - Phone:206-817-6586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA979438133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered