Healthcare Provider Details

I. General information

NPI: 1013871383
Provider Name (Legal Business Name): AMANDA ROSE VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 97TH PL
CORONA NY
11368-4380
US

IV. Provider business mailing address

9737 63RD RD APT 6J
REGO PARK NY
11374-1621
US

V. Phone/Fax

Practice location:
  • Phone: 718-424-8278
  • Fax:
Mailing address:
  • Phone: 718-269-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: