Healthcare Provider Details

I. General information

NPI: 1487178687
Provider Name (Legal Business Name): AMY MICHELLE PROVENZANO CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 02/02/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67A MOUNTAIN BOULEVARD EXT 1ST FLOOR, UNIT B
WARREN NJ
07059
US

IV. Provider business mailing address

751 ORWELL ST
LITHOPOLIS OH
43136-9723
US

V. Phone/Fax

Practice location:
  • Phone: 858-216-8837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP.021402
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNUR-2023-000730
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95022954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: