Healthcare Provider Details

I. General information

NPI: 1871415364
Provider Name (Legal Business Name): AMANDA IVANKOVIC TAGGART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18057 REPUBLIC AVE
PORT CHARLOTTE FL
33948-9370
US

IV. Provider business mailing address

18057 REPUBLIC AVE
PORT CHARLOTTE FL
33948-9370
US

V. Phone/Fax

Practice location:
  • Phone: 941-268-3593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.0324
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10282629
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1281097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: