Provider Demographics
NPI:1669262242
Name:KENNEDY, AMANDA LAUREN (MS, RDN, LDN, CLC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAUREN
Last Name:KENNEDY
Suffix:
Gender:
Credentials:MS, RDN, LDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 JOAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-5126
Mailing Address - Country:US
Mailing Address - Phone:678-227-0611
Mailing Address - Fax:
Practice Address - Street 1:2295 RONALD REAGAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5739
Practice Address - Country:US
Practice Address - Phone:770-982-4118
Practice Address - Fax:770-982-4104
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006263133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered