Provider Demographics
NPI:1831320365
Name:DULAC, AMANDA (RD)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:
Last Name:DULAC
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3543
Mailing Address - Country:US
Mailing Address - Phone:313-272-8450
Mailing Address - Fax:313-272-8455
Practice Address - Street 1:15801 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3543
Practice Address - Country:US
Practice Address - Phone:313-272-8450
Practice Address - Fax:313-272-8455
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI808188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered