Basic Information
| Provider Information | |||||||||
| NPI: | 1902424443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENACQUISTO | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 MANSION BLVD APT J | ||||||||
| Address2: | |||||||||
| City: | DELMAR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120542456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184914920 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 BURDETT AVE | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2020 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 678703 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 345607 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.