Provider Demographics
NPI:1326382094
Name:CLEVENGER, AMANDA (RPSGT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLEVENGER
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4354
Mailing Address - Country:US
Mailing Address - Phone:321-634-4051
Mailing Address - Fax:
Practice Address - Street 1:2123 FOXWOOD DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4354
Practice Address - Country:US
Practice Address - Phone:321-634-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18621246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other