Provider Demographics
NPI:1528570470
Name:GUERRA, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GUERRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GUERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMANDA GUERRA
Mailing Address - Street 1:3429 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3429 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-5381
Practice Address - Country:US
Practice Address - Phone:786-379-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid