Provider Demographics
NPI:1265067532
Name:IGLESIAS, AMY LYNN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:IGLESIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15138 NW 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1371
Mailing Address - Country:US
Mailing Address - Phone:305-905-2389
Mailing Address - Fax:
Practice Address - Street 1:4129 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2254
Practice Address - Country:US
Practice Address - Phone:813-580-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061851122300000X
390200000X
FLDN25195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program