Provider Demographics
NPI:1770047318
Name:ADRIAN, AMANDA GAYLE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GAYLE
Last Name:ADRIAN
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 1:300 S RANGE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-5113
Mailing Address - Country:US
Mailing Address - Phone:321-863-8143
Mailing Address - Fax:
Practice Address - Street 1:300 S RANGE RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5113
Practice Address - Country:US
Practice Address - Phone:321-863-8143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency