Healthcare Provider Details

I. General information

NPI: 1063225621
Provider Name (Legal Business Name): AMANDA ROA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 MIL SORPRESAS DR
FALLBROOK CA
92028-1833
US

IV. Provider business mailing address

2248 MIL SORPRESAS DR
FALLBROOK CA
92028-1833
US

V. Phone/Fax

Practice location:
  • Phone: 909-534-1615
  • Fax:
Mailing address:
  • Phone: 909-534-1615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: