Provider Demographics
NPI:1093791949
Name:ZITIELLO, AMY NICOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:NICOLE
Last Name:ZITIELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:SOURLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4150 WOODLANDS PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3495
Mailing Address - Country:US
Mailing Address - Phone:727-772-1452
Mailing Address - Fax:727-772-1453
Practice Address - Street 1:4150 WOODLANDS PKWY STE B
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3495
Practice Address - Country:US
Practice Address - Phone:727-772-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL059496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274579800Medicaid