MEDICARE: MISS AMANDA JO CROWLEY I FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F08210115	FL

General Provider Information

NPI Number	:	1679242366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMANDA JO CROWLEY I FNP

Provider Business Mailing Address
First Line	:	31754 RED TAIL BLVD
Second Line	:
City	:	SORRENTO
State	:	FL
Zip	:	32776-7764
Country	:	US
Telephone Number	:	941-525-7258
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 WEKIVA SPRINGS RD STE C
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-6051
Country	:	US
Telephone Number	:	941-525-7258
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2021
Last Update Date	:	09/07/2021

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