Healthcare Provider Details

I. General information

NPI: 1114557287
Provider Name (Legal Business Name): AMANDA JANKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 09/08/2024
Certification Date: 09/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VILLAGE GREEN DR
LITCHFIELD CT
06759-3433
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-567-0130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11834
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberSP021211
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: