Basic Information
| Provider Information | |||||||||
| NPI: | 1184841397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMPSON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9110 COLLEGE POINTE COURT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392082206 | ||||||||
| FaxNumber: | 2392083994 | ||||||||
| Practice Location | |||||||||
| Address1: | 9110 COLLEGE POINTE CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339193244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395604310 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 51225 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 24413 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 292792 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | TM00627 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD60595494 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 4301114050 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD171093 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35.126796 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME112121 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 008073900 | 05 | FL | MEDICAID | 006340000 | 05 | FL | MEDICAID |