Healthcare Provider Details

I. General information

NPI: 1245950773
Provider Name (Legal Business Name): AMY CHRISTINE POWELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 10/21/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 EAGLE HARBOR PKWY
FLEMING ISLAND FL
32003-4817
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-1366
  • Fax:
Mailing address:
  • Phone: 904-282-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11021687
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11021687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: