Provider Demographics
NPI:1326670589
Name:STACHURA, AMANDA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STACHURA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9204 HILLCROFT DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4742
Mailing Address - Country:US
Mailing Address - Phone:540-838-5990
Mailing Address - Fax:
Practice Address - Street 1:4729 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7113
Practice Address - Country:US
Practice Address - Phone:813-251-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily