Provider Demographics
NPI:1619370053
Name:WIRTH, AMANDA JENE (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JENE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 IMPERIAL BLVD STE B2
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4689
Mailing Address - Country:US
Mailing Address - Phone:813-684-2229
Mailing Address - Fax:813-413-8507
Practice Address - Street 1:215 IMPERIAL BLVD STE B2
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4689
Practice Address - Country:US
Practice Address - Phone:813-684-2229
Practice Address - Fax:813-413-8507
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16289363LW0102X, 363LW0102X
FLAPRN9482070363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024693700Medicaid
OH0111806Medicaid