Basic Information
| Provider Information | |||||||||
| NPI: | 1821218330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMOS | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | RD LD LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5204 SHOAL CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787561813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124588576 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1717 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787033907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124723142 | ||||||||
| FaxNumber: | 5124724008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | DT07166 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.