Provider Demographics
NPI:1285485821
Name:ERICSON, AMANDA CHRISTINE (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHRISTINE
Last Name:ERICSON
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 1:5398 GRANTSVILLE GRV APT 104
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2984
Mailing Address - Country:US
Mailing Address - Phone:760-521-0228
Mailing Address - Fax:
Practice Address - Street 1:5398 GRANTSVILLE GRV APT 104
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2984
Practice Address - Country:US
Practice Address - Phone:760-521-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86417522133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered