MEDICARE: AMY ELIZABETH BLANCKE AGACNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	AP142394	TX

General Provider Information

NPI Number	:	1538729421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY ELIZABETH BLANCKE AGACNP

Provider Business Mailing Address
First Line	:	P.O. BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 5TH AVE STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4386
Country	:	US
Telephone Number	:	817-423-8585
Fax Number	:	817-423-8458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	07/24/2019

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