Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 16770 | FL |
NPI | 1003100611 |
---|---|
Provider Name | Amanda Tristan |
First Address | South Miami, FL 33143-3524 |
Second Address | Miami, FL 33184-2808 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2011 |
Last Update Date | 21/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
014485800 | (05) | FL |