Provider Demographics
NPI:1700637329
Name:ROSENBERG, AMANDA LYNN (RDN)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:BACASTOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 PARKWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7332
Mailing Address - Country:US
Mailing Address - Phone:503-438-6897
Mailing Address - Fax:
Practice Address - Street 1:2489 DIPLOMAT PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5422
Practice Address - Country:US
Practice Address - Phone:239-652-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86040610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered