Provider Demographics
NPI:1811380058
Name:HERLOCKER, AMANDA (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HERLOCKER
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN, LDN
Mailing Address - Street 1:7940 WILLIAMS POND LN
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8766
Mailing Address - Country:US
Mailing Address - Phone:704-752-7779
Mailing Address - Fax:704-752-7775
Practice Address - Street 1:7940 WILLIAMS POND LN
Practice Address - Street 2:SUITE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8766
Practice Address - Country:US
Practice Address - Phone:704-752-7779
Practice Address - Fax:704-752-7775
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004062133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered