Healthcare Provider Details

I. General information

NPI: 1952836249
Provider Name (Legal Business Name): AMANDA LETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA FAITH COLLETT

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 JUDGE FRAN JAMIESON WAY
VIERA FL
32940-5998
US

IV. Provider business mailing address

2565 JUDGE FRAN JAMIESON WAY
VIERA FL
32940-5998
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-3688
  • Fax: 321-504-0955
Mailing address:
  • Phone: 321-634-3688
  • Fax: 321-504-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8017
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: