Provider Demographics
NPI:1851986996
Name:FELLIN, AMANDA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:FELLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 CITY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1610
Mailing Address - Country:US
Mailing Address - Phone:215-871-6100
Mailing Address - Fax:
Practice Address - Street 1:860 1ST AVE STE 8B
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-4033
Practice Address - Country:US
Practice Address - Phone:844-337-6362
Practice Address - Fax:646-665-3604
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJMA062795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program