Provider Demographics
NPI:1740793926
Name:AMEGNISSE, SANDRINE NADIA
Entity Type:Individual
Prefix:
First Name:SANDRINE
Middle Name:NADIA
Last Name:AMEGNISSE
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 1:1400 LAKE SHADOW CIR APT 10303
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7586
Mailing Address - Country:US
Mailing Address - Phone:321-203-9018
Mailing Address - Fax:
Practice Address - Street 1:1803 PARK CENTER DR STE 212
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6216
Practice Address - Country:US
Practice Address - Phone:321-203-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-27762103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst