Provider Demographics
NPI:1538846258
Name:INTISSAR, AMNE (AGACNP)
Entity type:Individual
Prefix:
First Name:AMNE
Middle Name:
Last Name:INTISSAR
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 OXFORD HILL RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6825
Mailing Address - Country:US
Mailing Address - Phone:206-579-7657
Mailing Address - Fax:
Practice Address - Street 1:241 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1154
Practice Address - Country:US
Practice Address - Phone:845-483-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027601363L00000X
MO2023018697363L00000X
NYF432647-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner