Provider Demographics
NPI:1558163576
Name:SPRINGWALDT, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SPRINGWALDT
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 1:2979 STATE ROUTE 209
Mailing Address - Street 2:
Mailing Address - City:WURTSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12790-4029
Mailing Address - Country:US
Mailing Address - Phone:845-649-9169
Mailing Address - Fax:
Practice Address - Street 1:15 JERSEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2438
Practice Address - Country:US
Practice Address - Phone:845-856-6681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist