Provider Demographics
NPI:1538786694
Name:WILLIS, AMY (PHD, RDN, LDN)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 AUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2229
Mailing Address - Country:US
Mailing Address - Phone:334-303-4135
Mailing Address - Fax:
Practice Address - Street 1:11711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5151
Practice Address - Country:US
Practice Address - Phone:301-203-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered