Provider Demographics
NPI:1063238665
Name:SKVORTSOV, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SKVORTSOV
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31193 E 64TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8529
Mailing Address - Country:US
Mailing Address - Phone:941-350-5179
Mailing Address - Fax:
Practice Address - Street 1:109 W COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4012
Practice Address - Country:US
Practice Address - Phone:918-887-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK221063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily