Provider Demographics
NPI:1104948454
Name:ELLIS, AMY CAMERON (RD, LDN)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:CAMERON
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2208
Mailing Address - Country:US
Mailing Address - Phone:704-332-5198
Mailing Address - Fax:
Practice Address - Street 1:1010 EDGEHILL RD N
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1885
Practice Address - Country:US
Practice Address - Phone:704-446-6252
Practice Address - Fax:704-355-9296
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered