Healthcare Provider Details

I. General information

NPI: 1487598769
Provider Name (Legal Business Name): AMANDA MAE DISTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 E EAGLE AVE
EAGLE LAKE FL
33839-3238
US

IV. Provider business mailing address

682 E EAGLE AVE
EAGLE LAKE FL
33839-3238
US

V. Phone/Fax

Practice location:
  • Phone: 440-417-4482
  • Fax:
Mailing address:
  • Phone: 440-417-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11046724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: