Provider Demographics
NPI:1114464765
Name:BUSTLE, AMANDA M (CPNP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:M
Last Name:BUSTLE
Suffix:
Gender:
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5827 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2000
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:
Practice Address - Street 1:2680 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014881363LP0200X
MI4704419600363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics