Healthcare Provider Details

I. General information

NPI: 1205009362
Provider Name (Legal Business Name): AMANDA MARIE BONAZZI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE MALEK

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 DEEPWOOD DR SUITE 104
ROUND ROCK TX
78681-4944
US

IV. Provider business mailing address

6500 NORTH MOPAC BUILDING 3 SUITE 200
AUSTIN TX
78731
US

V. Phone/Fax

Practice location:
  • Phone: 512-458-8400
  • Fax: 512-458-8593
Mailing address:
  • Phone: 512-458-8400
  • Fax: 512-458-8593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number721093
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: