Provider Demographics
NPI:1831553981
Name:HEINTZELMAN, AMANDA GOOD (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GOOD
Last Name:HEINTZELMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:336 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-3202
Mailing Address - Country:US
Mailing Address - Phone:508-566-6958
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 7683133V00000X
1052071133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered