Provider Demographics
NPI:1215335609
Name:CAMPBELL, AMY (RD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CAMPBELL
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 1:65 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7725
Mailing Address - Country:US
Mailing Address - Phone:781-647-7197
Mailing Address - Fax:
Practice Address - Street 1:65 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-7725
Practice Address - Country:US
Practice Address - Phone:781-647-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA293133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered