Provider Demographics
NPI:1568024537
Name:CROSSON, AMANDA MARIE (CNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:CROSSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:836 SUNSET LAKE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7555
Practice Address - Country:US
Practice Address - Phone:941-408-0500
Practice Address - Fax:941-496-8558
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN322320363LG0600X
FLAPRN11001934363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116411100Medicaid