Provider Demographics
NPI:1346678026
Name:COSTELLO, AMANDA (ARNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9310 HERITAGE OAK CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-5013
Mailing Address - Country:US
Mailing Address - Phone:727-808-0959
Mailing Address - Fax:813-333-5994
Practice Address - Street 1:18958 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-2829
Practice Address - Country:US
Practice Address - Phone:813-839-7390
Practice Address - Fax:813-333-5994
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013276363LP0808X
FLARNP 9415070363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01567509Medicaid
FLDTM1J019ZMedicare UPIN