Provider Demographics
NPI:1750077434
Name:CORLISS, AMANDA VALLEE (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VALLEE
Last Name:CORLISS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:VALLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:51 PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:ACUSHNET
Mailing Address - State:MA
Mailing Address - Zip Code:02743-2346
Mailing Address - Country:US
Mailing Address - Phone:508-688-4794
Mailing Address - Fax:
Practice Address - Street 1:51 PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:ACUSHNET
Practice Address - State:MA
Practice Address - Zip Code:02743-2346
Practice Address - Country:US
Practice Address - Phone:508-688-4794
Practice Address - Fax:508-974-9849
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered