Provider Demographics
NPI:1043757149
Name:SALLEY, AMANDA (MS, RD, CSP, LDN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SALLEY
Suffix:
Gender:
Credentials:MS, RD, CSP, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PALM COVE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8160
Mailing Address - Country:US
Mailing Address - Phone:260-804-2880
Mailing Address - Fax:
Practice Address - Street 1:129 PALM COVE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8160
Practice Address - Country:US
Practice Address - Phone:260-804-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006966133VN1004X
SC2758133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric