Provider Demographics
NPI:1851806467
Name:BALK, AMANDA (RD, LD, PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BALK
Suffix:
Gender:F
Credentials:RD, LD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BOYD ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 BOYD ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-1702
Practice Address - Country:US
Practice Address - Phone:636-282-0380
Practice Address - Fax:877-592-0806
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered