Provider Demographics
NPI:1366809873
Name:PHILLIPS, AMANDA (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3344 E GOLD DUST AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3947
Mailing Address - Country:US
Mailing Address - Phone:602-531-1457
Mailing Address - Fax:
Practice Address - Street 1:3344 E GOLD DUST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3947
Practice Address - Country:US
Practice Address - Phone:602-531-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ915708133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered