Healthcare Provider Details

I. General information

NPI: 1023260759
Provider Name (Legal Business Name): AMY STANGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY MCGINNIS

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 CULLEN LAKE SHORE DR
BELLE ISLE FL
32812
US

IV. Provider business mailing address

3430 CULLEN LAKE SHORE DR
BELLE ISLE FL
32812
US

V. Phone/Fax

Practice location:
  • Phone: 215-431-3374
  • Fax: 407-704-3088
Mailing address:
  • Phone: 215-431-3374
  • Fax: 407-704-3088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT12495
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: