Basic Information
| Provider Information | |||||||||
| NPI: | 1619370053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTH | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JENE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 IMPERIAL BLVD STE B2 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842229 | ||||||||
| FaxNumber: | 8134138507 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 IMPERIAL BLVD STE B2 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842229 | ||||||||
| FaxNumber: | 8134138507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2014 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 16289 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | APRN9482070 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 024693700 | 05 | FL | MEDICAID | 0111806 | 05 | OH | MEDICAID |