Provider Demographics
NPI:1891296554
Name:ALLEN, AMANDA MARCELLA (MS, RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARCELLA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MARCELLA
Other - Last Name:BROOMBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN, LD
Mailing Address - Street 1:1720 W BATTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5359
Mailing Address - Country:US
Mailing Address - Phone:417-881-1950
Mailing Address - Fax:
Practice Address - Street 1:1720 W BATTLEFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5359
Practice Address - Country:US
Practice Address - Phone:417-881-1950
Practice Address - Fax:417-881-8289
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016030257133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered