Provider Demographics
NPI:1104894310
Name:AMYX, AMY E (MNT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:AMYX
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W GLENN ELLYN DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2220
Mailing Address - Country:US
Mailing Address - Phone:765-281-2000
Mailing Address - Fax:765-281-2062
Practice Address - Street 1:800 S TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4529
Practice Address - Country:US
Practice Address - Phone:765-281-2000
Practice Address - Fax:765-281-2062
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001494A133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ01508Medicare UPIN
IN465610XXMedicare ID - Type Unspecified