Provider Demographics
NPI:1881358745
Name:SIMON, AMBER PELLETIER (RD, CLC)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:PELLETIER
Last Name:SIMON
Suffix:
Gender:F
Credentials:RD, CLC
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MARIE
Other - Last Name:PELLETIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2890 S FAIRFAX ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6839
Mailing Address - Country:US
Mailing Address - Phone:860-214-0139
Mailing Address - Fax:
Practice Address - Street 1:1039 OAK CIR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4535
Practice Address - Country:US
Practice Address - Phone:860-214-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO311226174N00000X
CO86081222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN