Provider Demographics
NPI:1285983346
Name:MALY, AMANDA (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MALY
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 1:2607 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1686
Mailing Address - Country:US
Mailing Address - Phone:262-522-8640
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-522-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2506-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered