Provider Demographics
NPI:1780634741
Name:SPAR, AMY LYNN (RD,LD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:SPAR
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 TOWNSHIP ROAD 55
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-9436
Mailing Address - Country:US
Mailing Address - Phone:419-634-5049
Mailing Address - Fax:
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2800
Practice Address - Country:US
Practice Address - Phone:419-226-5091
Practice Address - Fax:419-998-4721
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHL1108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSPMT71251Medicare UPIN