Healthcare Provider Details

I. General information

NPI: 1083606503
Provider Name (Legal Business Name): AMY L. COOPERSMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 DR CARTER BLVD
BUNNELL FL
32110-6212
US

IV. Provider business mailing address

51 RENWORTH LN
PALM COAST FL
32164-6627
US

V. Phone/Fax

Practice location:
  • Phone: 386-437-7350
  • Fax:
Mailing address:
  • Phone: 386-586-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9242220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: