Provider Demographics
NPI:1245617802
Name:FAGAN, AMANDA LYNNE (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNNE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNNE
Other - Last Name:STUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4613 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-1705
Mailing Address - Country:US
Mailing Address - Phone:407-232-9833
Mailing Address - Fax:407-232-9829
Practice Address - Street 1:4613 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-1705
Practice Address - Country:US
Practice Address - Phone:407-232-9833
Practice Address - Fax:407-232-9829
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO2319207Q00000X
NVSL1068207Q00000X
FLOS17191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine