Provider Demographics
NPI:1427618669
Name:MONTALVO, AMANDA J (RD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:J
Last Name:MONTALVO
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 1:226 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-5410
Mailing Address - Country:US
Mailing Address - Phone:860-424-6962
Mailing Address - Fax:
Practice Address - Street 1:226 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-5410
Practice Address - Country:US
Practice Address - Phone:860-424-6962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86011975133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86011975OtherN/A