Provider Demographics
NPI:1699138446
Name:HANEKOM, AMANDA ELAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ELAYNE
Last Name:HANEKOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:ELAYNE
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2454 WESTMINSTER TER
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7503
Mailing Address - Country:US
Mailing Address - Phone:407-276-5150
Mailing Address - Fax:
Practice Address - Street 1:2454 WESTMINSTER TER
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7503
Practice Address - Country:US
Practice Address - Phone:407-276-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME145987208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program