Provider Demographics
NPI:1780490250
Name:BOOTH, AMANDA L (RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CORAL DR
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-2502
Mailing Address - Country:US
Mailing Address - Phone:330-697-4424
Mailing Address - Fax:
Practice Address - Street 1:250 CORAL DR
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-2502
Practice Address - Country:US
Practice Address - Phone:330-697-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9518481163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse