Provider Demographics
NPI:1760998595
Name:BERCKES, AMANDA (MS, RD, LN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BERCKES
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 HAARFAGER AVE S
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:MN
Mailing Address - Zip Code:56220-1423
Mailing Address - Country:US
Mailing Address - Phone:605-880-1455
Mailing Address - Fax:
Practice Address - Street 1:450 EASTVOLD AVE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1252
Practice Address - Country:US
Practice Address - Phone:605-880-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN225133N00000X
SD0611133N00000X
86059182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist