Provider Demographics
NPI:1689945420
Name:MAGNOLI, AMANDA ELIZABETH (ANP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:MAGNOLI
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0911
Mailing Address - Country:US
Mailing Address - Phone:207-303-3200
Mailing Address - Fax:207-250-2140
Practice Address - Street 1:100 CAMPUS DR UNIT 108
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7172
Practice Address - Country:US
Practice Address - Phone:207-303-3300
Practice Address - Fax:207-250-2139
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX846102363L00000X
CT004742363LA2200X
MECNP151089363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328301201Medicaid
TX8148NFOtherBCBS
TX328301201Medicaid