Provider Demographics
NPI:1275081432
Name:PHOENIX, AMANDA ROSE (PHARMD, BCACP, CDE)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ROSE
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:PHARMD, BCACP, CDE
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:MAIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:56 BROOK MANOR LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-2416
Mailing Address - Country:US
Mailing Address - Phone:631-835-3311
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:631-835-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061184183500000X, 1835P2201X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05752314Medicaid
NY05752534Medicaid