Provider Demographics
NPI:1720556590
Name:FENTRESS, AMBER ROSE (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ROSE
Last Name:FENTRESS
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 1:1106 BROAD ST APT G
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-1118
Mailing Address - Country:US
Mailing Address - Phone:812-719-9619
Mailing Address - Fax:
Practice Address - Street 1:1465 LANEY WALKER BLVD # 1040
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0002
Practice Address - Country:US
Practice Address - Phone:706-721-3448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered