Provider Demographics
NPI:1558677484
Name:RODRIGUEZ, AMANDA (CNM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4501
Mailing Address - Country:US
Mailing Address - Phone:850-769-0338
Mailing Address - Fax:
Practice Address - Street 1:103 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-769-0338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9491261363LX0001X
367A00000X
IN28156709A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201000440Medicaid
IN000000993054OtherANTHEM PROVIDER NUMBER
IN201000440Medicaid