Provider Demographics
NPI:1972923910
Name:WALKER, AMANDA (RDLD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 MCMAHON BLVD NW
Mailing Address - Street 2:SUITE 245
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5090
Mailing Address - Country:US
Mailing Address - Phone:505-727-2300
Mailing Address - Fax:
Practice Address - Street 1:4801 MCMAHON BLVD NW
Practice Address - Street 2:SUITE 245
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5090
Practice Address - Country:US
Practice Address - Phone:505-727-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004056133V00000X
NMLD-1123133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22180079Medicaid