Provider Demographics
NPI:1265181242
Name:DEVILLIERS, AMANDA JEANETTE (CNS, LDN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANETTE
Last Name:DEVILLIERS
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S 51ST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1607
Mailing Address - Country:US
Mailing Address - Phone:570-575-6353
Mailing Address - Fax:
Practice Address - Street 1:417 S 51ST ST APT 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1607
Practice Address - Country:US
Practice Address - Phone:570-575-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006941133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN006941OtherDIETITIAN-NUTRITIONIST (LDN)
17610OtherCERTIFIED NUTRITION SPECIALIST (CNS)