Provider Demographics
NPI:1083256291
Name:FANTINO, AMANDA LYNN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:FANTINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5240 E GALBRAITH RD STE A
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-2879
Mailing Address - Country:US
Mailing Address - Phone:513-721-7533
Mailing Address - Fax:
Practice Address - Street 1:5240 E GALBRAITH RD STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2879
Practice Address - Country:US
Practice Address - Phone:513-721-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH024671363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner