Provider Demographics
NPI:1124035456
Name:VEZZA, AMY (CRNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VEZZA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15851-1282
Mailing Address - Country:US
Mailing Address - Phone:814-375-6000
Mailing Address - Fax:814-375-9503
Practice Address - Street 1:90 BEAVER DR
Practice Address - Street 2:SUITE 211D
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2440
Practice Address - Country:US
Practice Address - Phone:814-375-6000
Practice Address - Fax:814-375-9503
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP-005236-B363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS64033Medicare UPIN
PA018825Medicare ID - Type Unspecified