Provider Demographics
NPI:1780714808
Name:CONRAD, AMANDA GLADNEY (MS, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GLADNEY
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 KIRKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-4113
Mailing Address - Country:US
Mailing Address - Phone:662-324-0309
Mailing Address - Fax:662-324-0309
Practice Address - Street 1:117 KIRKSIDE DR
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4113
Practice Address - Country:US
Practice Address - Phone:662-324-0309
Practice Address - Fax:662-324-0309
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1120133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered