Provider Demographics
NPI:1720657133
Name:DECELLE, AMY M (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:DECELLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 NW 76TH TER
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:808 NW 76TH TER
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1443
Practice Address - Country:US
Practice Address - Phone:786-408-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical