Provider Demographics
NPI:1235833252
Name:AMILCA, MAUREEN DIANE
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:DIANE
Last Name:AMILCA
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 1:602 S AUDUBON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4217
Mailing Address - Country:US
Mailing Address - Phone:321-693-3395
Mailing Address - Fax:
Practice Address - Street 1:10623 MASSIMO DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-2010
Practice Address - Country:US
Practice Address - Phone:321-693-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner