Provider Demographics
NPI:1063015469
Name:AMENDOLIA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:AMENDOLIA
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 1:235 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:EGG HBR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-8003
Mailing Address - Country:US
Mailing Address - Phone:609-335-9585
Mailing Address - Fax:
Practice Address - Street 1:54 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9438
Practice Address - Country:US
Practice Address - Phone:609-652-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01064900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner