Provider Demographics
NPI:1578160297
Name:EVANGELISTA, AMANDA CHRISTINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHRISTINE
Last Name:EVANGELISTA
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 1:2119 SE DESTIN DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-8000
Mailing Address - Country:US
Mailing Address - Phone:609-402-5496
Mailing Address - Fax:
Practice Address - Street 1:2119 SE DESTIN DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-8000
Practice Address - Country:US
Practice Address - Phone:609-402-5496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLOTA19374224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician