Provider Demographics
NPI:1124887971
Name:LAEZZA, AMANDA MARIA (RDN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIA
Last Name:LAEZZA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 FAWN CT
Mailing Address - Street 2:
Mailing Address - City:MONROE TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1180
Mailing Address - Country:US
Mailing Address - Phone:908-930-0353
Mailing Address - Fax:
Practice Address - Street 1:383 W FOUNTAIN ST STE 115
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3515
Practice Address - Country:US
Practice Address - Phone:401-297-3256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered