Provider Demographics
NPI:1548820020
Name:DIAZ, AMANDA LEAL (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEAL
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MITCHELL BLVD BLDG 375
Mailing Address - Street 2:
Mailing Address - City:LAUGHLIN AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78840
Mailing Address - Country:US
Mailing Address - Phone:830-298-6407
Mailing Address - Fax:
Practice Address - Street 1:39TH MEDICAL GROUP
Practice Address - Street 2:UNIT 7095
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09824-5185
Practice Address - Country:US
Practice Address - Phone:314-676-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85615133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered