Provider Demographics
NPI:1326789454
Name:PUELLO, AMANDA VICTORIA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:PUELLO
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 1:1707 W ERNA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-821-8038
Practice Address - Fax:813-974-4325
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018206363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLYL20GOtherBLUE CROSS BLUE SHIELD
FL113959100Medicaid