Provider Demographics
NPI:1881034056
Name:BREWSAUGH, AMANDA (RD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BREWSAUGH
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 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1815
Mailing Address - Country:US
Mailing Address - Phone:937-641-5310
Mailing Address - Fax:203-688-2410
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001134133V00000X
OH1069423133VN1004X
OHLD.7583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02658OtherYALE NEW HAVEN HOSPITAL MEDICARE NUMBER
CT001134OtherSTATE CERTIFICATION