Provider Demographics
NPI:1073919759
Name:TALBOT, AMANDA (RN)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:
Last Name:TALBOT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2241
Mailing Address - Country:US
Mailing Address - Phone:631-599-8151
Mailing Address - Fax:
Practice Address - Street 1:39 MITCHELL DR
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-2241
Practice Address - Country:US
Practice Address - Phone:631-599-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY689012163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY689012Medicaid