Provider Demographics
NPI:1134774003
Name:IRVINE, AMANDA AGNES (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:AGNES
Last Name:IRVINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:AGNES
Other - Last Name:TAILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-2575
Mailing Address - Fax:585-922-5033
Practice Address - Street 1:1455 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2006
Practice Address - Country:US
Practice Address - Phone:585-922-2575
Practice Address - Fax:585-922-5033
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383047363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics