Provider Demographics
NPI:1316401623
Name:ICAZATTI-BURTELL, AMANDA MERCEDES
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MERCEDES
Last Name:ICAZATTI-BURTELL
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 1:700 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4924
Mailing Address - Country:US
Mailing Address - Phone:407-846-2266
Mailing Address - Fax:
Practice Address - Street 1:700 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4924
Practice Address - Country:US
Practice Address - Phone:407-846-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167636207P00000X
390200000X
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program