Provider Demographics
NPI:1225428303
Name:CERVINI, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CERVINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4321
Mailing Address - Country:US
Mailing Address - Phone:631-624-1763
Mailing Address - Fax:
Practice Address - Street 1:34 WENWOOD DR
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4321
Practice Address - Country:US
Practice Address - Phone:631-624-1763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31683-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM00D22842Medicaid