Provider Demographics
NPI:1790506228
Name:CORALLO, AMANDA DANIELLE (CRNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:CORALLO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 CARNATION DR
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2114
Mailing Address - Country:US
Mailing Address - Phone:570-955-6169
Mailing Address - Fax:
Practice Address - Street 1:7250 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-1388
Practice Address - Country:US
Practice Address - Phone:443-949-0814
Practice Address - Fax:443-949-0825
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP030928363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology