Provider Demographics
NPI:1104419134
Name:BENNER, AMBER E (MS, RD/RDN, LDN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:E
Last Name:BENNER
Suffix:
Gender:F
Credentials:MS, RD/RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 BROOK RUN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-9732
Mailing Address - Country:US
Mailing Address - Phone:919-500-3231
Mailing Address - Fax:
Practice Address - Street 1:1660 BROOK RUN DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-9732
Practice Address - Country:US
Practice Address - Phone:919-500-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLN004521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL004521OtherNORTH CAROLINA BOARD OF DIETETICS/NUTRITION
86039138OtherCOMMISSION ON DIETETIC REGISTRATION