Provider Demographics
NPI:1861741241
Name:ELLIS, AMY DAWN (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5907
Mailing Address - Street 2:HIGHWAY 169 MILE MARKER 29
Mailing Address - City:ALAMO
Mailing Address - State:NM
Mailing Address - Zip Code:87825-5907
Mailing Address - Country:US
Mailing Address - Phone:575-854-2642
Mailing Address - Fax:575-854-2606
Practice Address - Street 1:HIGHWAY 169 MILE MARKER 29
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:NM
Practice Address - Zip Code:87825-5907
Practice Address - Country:US
Practice Address - Phone:575-854-2642
Practice Address - Fax:575-854-2606
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered