Provider Demographics
NPI:1902151749
Name:HAMPTON, AMY LEIGH
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEIGH
Last Name:HAMPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-1931
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:9800 N LAMAR BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4160
Practice Address - Country:US
Practice Address - Phone:512-527-9608
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82117133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN