Provider Demographics
NPI:1831692128
Name:MOOMAW, AMY SUE (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:MOOMAW
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 GRACE CORPENING DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-5864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:348 GRACE CORPENING DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-5864
Practice Address - Country:US
Practice Address - Phone:828-559-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001880133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL001880OtherRD LICENSE