Provider Demographics
NPI:1396507125
Name:STEPHENS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2262 HIDDEN MDW
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-4831
Mailing Address - Country:US
Mailing Address - Phone:512-665-2740
Mailing Address - Fax:
Practice Address - Street 1:2115 STEPHENS PL STE 400B
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-2167
Practice Address - Country:US
Practice Address - Phone:210-439-1714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84342133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered