Provider Demographics
NPI:1730295288
Name:BROGNO, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BROGNO
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 1:6595 B E ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19149
Mailing Address - Country:US
Mailing Address - Phone:215-743-2332
Mailing Address - Fax:
Practice Address - Street 1:6595 B E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19149
Practice Address - Country:US
Practice Address - Phone:215-743-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2877OtherLICENSE #