Provider Demographics
NPI:1124750187
Name:MATSUMOTO, AMY KAYE (RD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KAYE
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:864-423-4266
Mailing Address - Fax:
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4303
Practice Address - Country:US
Practice Address - Phone:980-330-6808
Practice Address - Fax:980-330-6938
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCL006973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered