Basic Information
| Provider Information | |||||||||
| NPI: | 1255574299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMSTUTZ | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACKE | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 750 W HIGH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192277399 | ||||||||
| FaxNumber: | 4192290123 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 W HIGH ST | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965069 | ||||||||
| FaxNumber: | 4199965424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2009 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD6291 | OH | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.