Healthcare Provider Details

I. General information

NPI: 1043747579
Provider Name (Legal Business Name): AMANDA JO PRESTIGIACOMO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N HAVEN DR
TWIN FALLS ID
83301-5788
US

IV. Provider business mailing address

PO BOX 268934
OKLAHOMA CITY OK
73126-8934
US

V. Phone/Fax

Practice location:
  • Phone: 208-904-4780
  • Fax: 208-904-4832
Mailing address:
  • Phone: 208-904-4780
  • Fax: 208-904-4832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number55632
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: