Provider Demographics
NPI:1245701796
Name:CONNORS, AMANDA MICHELLE (MS, RD, CDN, CNSC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:CONNORS
Suffix:
Gender:F
Credentials:MS, RD, CDN, CNSC
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 BRIGHT LEAF LOOP
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8274
Mailing Address - Country:US
Mailing Address - Phone:845-661-8993
Mailing Address - Fax:
Practice Address - Street 1:505 BRIGHT LEAF LOOP
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8274
Practice Address - Country:US
Practice Address - Phone:845-661-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86108396133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered