Provider Demographics
NPI:1023860061
Name:IMMERBLUM, AMANDA EVE (MS, FNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:EVE
Last Name:IMMERBLUM
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SMITH LN
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-1922
Mailing Address - Country:US
Mailing Address - Phone:914-844-6119
Mailing Address - Fax:
Practice Address - Street 1:256 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2766
Practice Address - Country:US
Practice Address - Phone:973-743-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713221163W00000X
NJ26NR24627100163W00000X
NY353866363LF0000X
NJ26NJ15046300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse