Provider Demographics
NPI:1245051507
Name:DESHPANDE, AMRUTA
Entity type:Individual
Prefix:
First Name:AMRUTA
Middle Name:
Last Name:DESHPANDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 EDDIE LEWIS DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-1545
Mailing Address - Country:US
Mailing Address - Phone:862-307-5883
Mailing Address - Fax:
Practice Address - Street 1:245 EDDIE LEWIS DR
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-1545
Practice Address - Country:US
Practice Address - Phone:862-307-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered