Provider Demographics
NPI:1003100611
Name:TRISTAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TRISTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:TRISTAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5920 SW 68TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3524
Mailing Address - Country:US
Mailing Address - Phone:305-665-0886
Mailing Address - Fax:305-667-4349
Practice Address - Street 1:1101 SW 122ND AVE APT 113
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2808
Practice Address - Country:US
Practice Address - Phone:786-281-7702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16770225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014485800Medicaid