Provider Demographics
NPI:1538633300
Name:SERRA, AMANDA TRACI
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:TRACI
Last Name:SERRA
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 1:10 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-1511
Mailing Address - Country:US
Mailing Address - Phone:607-227-4756
Mailing Address - Fax:
Practice Address - Street 1:10 MEADOW LN
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1511
Practice Address - Country:US
Practice Address - Phone:607-227-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8001363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health