Provider Demographics
NPI:1104374503
Name:PUMILIA, AMANDA S (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:PUMILIA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:SWAGGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:BOX 78534
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278
Mailing Address - Country:US
Mailing Address - Phone:815-398-9491
Mailing Address - Fax:815-381-7498
Practice Address - Street 1:1641 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1018
Practice Address - Country:US
Practice Address - Phone:419-629-6262
Practice Address - Fax:941-629-1782
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-348345163W00000X
IL209-014962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid