Provider Demographics
NPI:1194058354
Name:HERTZ, AMY (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:HERTZ
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:RICHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1905 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3163
Mailing Address - Country:US
Mailing Address - Phone:815-936-6515
Mailing Address - Fax:815-936-6517
Practice Address - Street 1:1905 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3163
Practice Address - Country:US
Practice Address - Phone:815-936-6515
Practice Address - Fax:815-936-6517
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.000560133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered