Provider Demographics
NPI:1285313817
Name:FITZGERALD, AMANDA (SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 ELM ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-1188
Mailing Address - Country:US
Mailing Address - Phone:651-460-6285
Mailing Address - Fax:
Practice Address - Street 1:905 ELM ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1188
Practice Address - Country:US
Practice Address - Phone:651-460-6285
Practice Address - Fax:651-252-2065
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist