Provider Demographics
NPI:1194609768
Name:DRISCOLL, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DRISCOLL
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 1:26 FAIRWAY LN
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6129
Mailing Address - Country:US
Mailing Address - Phone:631-521-5497
Mailing Address - Fax:
Practice Address - Street 1:265 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4833
Practice Address - Country:US
Practice Address - Phone:631-450-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY769098163WS0200X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical