Basic Information
| Provider Information | |||||||||
| NPI: | 1689922403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLIN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739728 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Practice Location | |||||||||
| Address1: | 11141 PARKVIEW PLAZA DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603478187 | ||||||||
| FaxNumber: | 2603478023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 37002215A | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.