Provider Demographics
NPI:1124351549
Name:BRENCI, AMANDA L (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:L
Last Name:BRENCI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 JOHN SIMS PKWY E
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2752
Mailing Address - Country:US
Mailing Address - Phone:850-678-8876
Mailing Address - Fax:
Practice Address - Street 1:1187 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2752
Practice Address - Country:US
Practice Address - Phone:850-678-8876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 004498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCQ292AMedicare UPIN