Provider Demographics
NPI:1144622051
Name:BOUQUE, AMANDA (AP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOUQUE
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 WESTWOOD SQ
Mailing Address - Street 2:SUITE A
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2892 CAREW AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:219-730-3189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist