Provider Demographics
NPI:1821218330
Name:AMOS, TERESA JOY (RD LD LVN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:JOY
Last Name:AMOS
Suffix:
Gender:F
Credentials:RD LD LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 SHOAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-1813
Mailing Address - Country:US
Mailing Address - Phone:512-458-8576
Mailing Address - Fax:
Practice Address - Street 1:1717 W 10TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-3907
Practice Address - Country:US
Practice Address - Phone:512-472-3142
Practice Address - Fax:512-472-4008
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered