Provider Demographics
NPI:1003701335
Name:ROSS, AMANDA R
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 LEGHORN RD
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-4105
Mailing Address - Country:US
Mailing Address - Phone:321-576-5538
Mailing Address - Fax:
Practice Address - Street 1:3880 LEGHORN RD
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-4105
Practice Address - Country:US
Practice Address - Phone:321-576-5538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL280498174H00000X
NY280498174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth Educator