Healthcare Provider Details

I. General information

NPI: 1710387279
Provider Name (Legal Business Name): AMANDA J WESTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W ROE BLVD
PATCHOGUE NY
11772-2569
US

IV. Provider business mailing address

122 W ROE BLVD
PATCHOGUE NY
11772-2569
US

V. Phone/Fax

Practice location:
  • Phone: 631-260-1314
  • Fax:
Mailing address:
  • Phone: 631-260-1314
  • Fax: 631-532-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401895
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierF401895-1
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerLICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: