Provider Demographics
NPI:1689922403
Name:BOLIN, AMANDA MICHELLE (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:BOLIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-458-5664
Practice Address - Street 1:11141 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1713
Practice Address - Country:US
Practice Address - Phone:260-347-8187
Practice Address - Fax:260-347-8023
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002215A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400075741Medicare PIN