Basic Information
Provider Information
NPI: 1003295718
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BILBO
FirstName: AMY
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: MS, RD, LD, CNSC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3316 RITCH AVE
Address2:  
City: CHARLOTTE
State: NC
PostalCode: 282062010
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 165 ASHLEY AVE
Address2: MSC 905
City: CHARLESTON
State: SC
PostalCode: 294259050
CountryCode: US
TelephoneNumber: 8438767271
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/27/2015
LastUpdateDate: 05/27/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
133V00000X1301SCY Dietary & Nutritional Service ProvidersDietitian, Registered 

No ID Information.


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