Provider Demographics
NPI:1710450762
Name:TREVINO, AMANDA LEE (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:TREVINO
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 1:3183 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-7826
Mailing Address - Country:US
Mailing Address - Phone:417-755-6486
Mailing Address - Fax:
Practice Address - Street 1:222 E PRIMROSE ST STE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5233
Practice Address - Country:US
Practice Address - Phone:417-888-0167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018044128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily