Healthcare Provider Details

I. General information

NPI: 1063349033
Provider Name (Legal Business Name): AMANDA ANN D'AGOSTINO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MARY ELMER DR
BRIDGETON NJ
08302-3903
US

IV. Provider business mailing address

41 MARY ELMER DR
BRIDGETON NJ
08302-3903
US

V. Phone/Fax

Practice location:
  • Phone: 856-217-2079
  • Fax:
Mailing address:
  • Phone: 856-217-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15563700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: