Provider Demographics
NPI:1063053700
Name:COOK, AMANDA (LDN, CNS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LDN, CNS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7661 BLUEBERRY HILL LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7973
Mailing Address - Country:US
Mailing Address - Phone:410-507-1071
Mailing Address - Fax:
Practice Address - Street 1:7500 HANOVER PKWY STE 105A
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2011
Practice Address - Country:US
Practice Address - Phone:301-220-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4817133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty