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General NPI Number Information
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NPI Number | 1487178687
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Entity Type | Individual
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Provider Name | AMY MICHELLE PROVENZANO CPNP-PC
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Gender | Female
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Dates
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Enumeration Date | 07/28/2017
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Last Update Date | 02/02/2023
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Provider Practice Location Address
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Address Line | 67A MOUNTAIN BOULEVARD EXT 1ST FLOOR, UNIT B
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City | WARREN
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State | NJ
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Zip | 07059
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Country | US
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Telephone | 858-216-8837
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Fax |
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Provider Business Mailing Address
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Address Line | 751 ORWELL ST
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City | LITHOPOLIS
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State | OH
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Zip | 43136-9723
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | APRN.CNP.021402
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | NUR-2023-000730
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 95022954
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License Number State | CA
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