Provider Demographics
NPI:1952022725
Name:NELSON, AMANDA RAE (RD)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3567 W 22ND PL UNIT E
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7623
Mailing Address - Country:US
Mailing Address - Phone:262-705-0147
Mailing Address - Fax:
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7170
Practice Address - Country:US
Practice Address - Phone:928-600-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86170092133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered