Provider Demographics
NPI:1386929164
Name:MIZUKI, AMBER (RD)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:
Last Name:MIZUKI
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 1:100 EMANCIPATION DRIVE
Mailing Address - Street 2:BLDG 116
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DRIVE
Practice Address - Street 2:BLDG 116
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01000859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered