Provider Demographics
NPI:1174376156
Name:FUNICIELLO, AMANDA (DC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FUNICIELLO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 POTTER ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4031
Mailing Address - Country:US
Mailing Address - Phone:631-786-3166
Mailing Address - Fax:
Practice Address - Street 1:301 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4900
Practice Address - Country:US
Practice Address - Phone:631-543-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013671111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor