Healthcare Provider Details

I. General information

NPI: 1295145845
Provider Name (Legal Business Name): AMANDA MARIE KILLMORE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE VALENTI CRNA

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

4900 BROAD RD
SYRACUSE NY
13215-2265
US

V. Phone/Fax

Practice location:
  • Phone: 315-299-5451
  • Fax:
Mailing address:
  • Phone: 315-492-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number555083-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: