Provider Demographics
NPI:1053100255
Name:WALL, AMBER (RDN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WALL
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GROVETHORN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4827
Mailing Address - Country:US
Mailing Address - Phone:443-425-0619
Mailing Address - Fax:
Practice Address - Street 1:5020 CAMPBELL BLVD STE L&M
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4968
Practice Address - Country:US
Practice Address - Phone:410-870-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86358177133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered