Provider Demographics
NPI:1235722711
Name:PETITO, AMANDA NICOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:PETITO
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 1:20646 ALBERMARLE LN
Mailing Address - Street 2:
Mailing Address - City:MILLSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19966-7564
Mailing Address - Country:US
Mailing Address - Phone:609-617-4003
Mailing Address - Fax:
Practice Address - Street 1:20646 ALBERMARLE LN
Practice Address - Street 2:
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-7564
Practice Address - Country:US
Practice Address - Phone:609-617-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU2-0002057225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist