Provider Demographics
NPI:1407689664
Name:SURUJBALI, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SURUJBALI
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 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 460
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6001
Practice Address - Country:US
Practice Address - Phone:813-879-4328
Practice Address - Fax:813-443-8152
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034927363LA2100X
FLAPRN11034927363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care