Provider Demographics
NPI:1245883305
Name:STEGMANN, AMANDA RUTH (LDN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RUTH
Last Name:STEGMANN
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RUTH
Other - Last Name:STEGMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:158 COTTAGE ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-3157
Mailing Address - Country:US
Mailing Address - Phone:207-837-4080
Mailing Address - Fax:
Practice Address - Street 1:158 COTTAGE ST APT 1R
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-3157
Practice Address - Country:US
Practice Address - Phone:207-837-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4793133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty