Provider Demographics
NPI:1902656978
Name:PELLETIER, AMANDA MARIE (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:PELLETIER
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 CROOKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5809
Mailing Address - Country:US
Mailing Address - Phone:248-654-6499
Mailing Address - Fax:
Practice Address - Street 1:4967 CROOKS RD STE 250
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5809
Practice Address - Country:US
Practice Address - Phone:248-654-6499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319507363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics