Healthcare Provider Details

I. General information

NPI: 1821862210
Provider Name (Legal Business Name): AMANDA CAUDILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W AIRPORT FWY STE 230
IRVING TX
75062-6297
US

IV. Provider business mailing address

9441 LBJ FWY STE 114
DALLAS TX
75243-4635
US

V. Phone/Fax

Practice location:
  • Phone: 214-557-4111
  • Fax:
Mailing address:
  • Phone: 214-557-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1140693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: