Provider Demographics
NPI:1720533516
Name:MARGOLIN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MARGOLIN
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 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 161
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 161
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-216-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10165396133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric