Provider Demographics
NPI:1487178687
Name:PROVENZANO, AMY MICHELLE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 ORWELL ST
Mailing Address - Street 2:
Mailing Address - City:LITHOPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:43136-9723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67A MOUNTAIN BOULEVARD EXT
Practice Address - Street 2:1ST FLOOR, UNIT B
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059
Practice Address - Country:US
Practice Address - Phone:858-216-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021402363LP0200X
NJNUR-2023-000730363LP0200X
CA95022954363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics