Provider Demographics
NPI:1912400771
Name:DEWEESE, AMANDA M (MPH, CPH, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:M
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:MPH, CPH, IBCLC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 MARCHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 MARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-7764
Practice Address - Country:US
Practice Address - Phone:813-205-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL-116572174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN