Provider Demographics
NPI:1770856296
Name:SHULTS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHULTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411B DYSINGER RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-9398
Mailing Address - Country:US
Mailing Address - Phone:716-266-6056
Mailing Address - Fax:716-332-6412
Practice Address - Street 1:6411B DYSINGER RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-9398
Practice Address - Country:US
Practice Address - Phone:716-266-6056
Practice Address - Fax:716-332-6412
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0072861133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered