Provider Demographics
NPI:1902424443
Name:BENACQUISTO, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BENACQUISTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MANSION BLVD APT J
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2456
Mailing Address - Country:US
Mailing Address - Phone:518-491-4920
Mailing Address - Fax:
Practice Address - Street 1:2215 BURDETT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-271-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY678703163W00000X
NY345607363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse