Provider Demographics
NPI:1316401623
Name:ICAZATTI-BURTELL, AMANDA MERCEDES
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MERCEDES
Last Name:ICAZATTI-BURTELL
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:HOSPITAL DR. FEDERICO TRILLA
Mailing Address - Street 2:KM 8 PR 3, AVE 65 DE INFANTERIA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984
Mailing Address - Country:US
Mailing Address - Phone:787-204-1426
Mailing Address - Fax:
Practice Address - Street 1:VILLA DEL REY 2
Practice Address - Street 2:2A19 CALLE BONAPARTE
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6214
Practice Address - Country:US
Practice Address - Phone:787-204-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program