Provider Demographics
NPI:1124617790
Name:MOORE, AMY MICHELLE (PHD RD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 HAUPT AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-1218
Mailing Address - Country:US
Mailing Address - Phone:740-591-7984
Mailing Address - Fax:
Practice Address - Street 1:138 HAUPT AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-1218
Practice Address - Country:US
Practice Address - Phone:740-591-7984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86058097133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered