Provider Demographics
NPI:1043747579
Name:PRESTIGIACOMO, AMANDA JO (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JO
Last Name:PRESTIGIACOMO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 268934
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8934
Mailing Address - Country:US
Mailing Address - Phone:208-904-4780
Mailing Address - Fax:208-904-4832
Practice Address - Street 1:350 N HAVEN DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5788
Practice Address - Country:US
Practice Address - Phone:208-904-4780
Practice Address - Fax:208-904-4832
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55632363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner