Provider Demographics
NPI:1356533566
Name:COPPEDGE, AMANDA NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICOLE
Last Name:COPPEDGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N LECANTO HWY
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9191
Mailing Address - Country:US
Mailing Address - Phone:352-746-2246
Mailing Address - Fax:
Practice Address - Street 1:240 N. LECANTO HWY.
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461
Practice Address - Country:US
Practice Address - Phone:352-746-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-11
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001339500Medicaid
FL001339500Medicaid