Provider Demographics
NPI:1578882981
Name:AMUNDSON, MICHELE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:AMUNDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3972
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2113
Practice Address - Country:US
Practice Address - Phone:845-856-3812
Practice Address - Fax:845-856-3820
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336293-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily