Basic Information
| Provider Information | |||||||||
| NPI: | 1881026300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEDEWA | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | FOOD AND NUTRITION DEPARTMENT BA1565 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695522836 | ||||||||
| FaxNumber: | 2695522964 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 SHAFFER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692265965 | ||||||||
| FaxNumber: | 2692265056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2013 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD004098 | GA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 86012347 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.