Provider Demographics
NPI:1326510744
Name:GILLEY, AMANDA BREANNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BREANNE
Last Name:GILLEY
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 1:3452 CASTLE STONE CT
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3339
Mailing Address - Country:US
Mailing Address - Phone:813-727-0416
Mailing Address - Fax:
Practice Address - Street 1:3452 CASTLE STONE CT
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-3339
Practice Address - Country:US
Practice Address - Phone:813-727-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-24
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0238357003747P1801X
FL1000737303747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant