Provider Demographics
NPI:1881136612
Name:MELLOWSPRING, AMANDA (MS,RD,CEDRD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MELLOWSPRING
Suffix:
Gender:F
Credentials:MS,RD,CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-5210
Mailing Address - Country:US
Mailing Address - Phone:540-505-4663
Mailing Address - Fax:540-953-5095
Practice Address - Street 1:708 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-5210
Practice Address - Country:US
Practice Address - Phone:540-505-4663
Practice Address - Fax:540-953-5095
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
953736133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered