Provider Demographics
NPI:1881026300
Name:FEDEWA, AMY LYNN (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:FEDEWA
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 1:5943 STADIUM DR
Mailing Address - Street 2:FOOD AND NUTRITION DEPARTMENT BA1565
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:269-552-2836
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1647
Practice Address - Country:US
Practice Address - Phone:269-226-5965
Practice Address - Fax:269-226-5056
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004098133V00000X
MI86012347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered