Provider Demographics
NPI:1124415450
Name:GOLDWEBER, AMY
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:GOLDWEBER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-2233
Mailing Address - Country:US
Mailing Address - Phone:617-833-0028
Mailing Address - Fax:
Practice Address - Street 1:415 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-2233
Practice Address - Country:US
Practice Address - Phone:617-833-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127969133V00000X
TXDT90700133V00000X
WI5809-29133V00000X
GALD007281133V00000X
NCL005572133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered