Provider Demographics
NPI:1720630585
Name:AVERETT, AMANDA ELLEN (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELLEN
Last Name:AVERETT
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 BENTRIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2826
Mailing Address - Country:US
Mailing Address - Phone:919-603-7631
Mailing Address - Fax:
Practice Address - Street 1:19607 W CATAWBA AVE STE 102
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4042
Practice Address - Country:US
Practice Address - Phone:919-603-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005831133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered