Provider Demographics
NPI:1851528566
Name:AVERY, AMANDA (NP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4343
Mailing Address - Country:US
Mailing Address - Phone:315-798-8868
Mailing Address - Fax:315-733-7105
Practice Address - Street 1:1427 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4343
Practice Address - Country:US
Practice Address - Phone:315-798-8868
Practice Address - Fax:315-733-7105
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382062363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics