Healthcare Provider Details

I. General information

NPI: 1376827477
Provider Name (Legal Business Name): AMANDA HENRIETTA GILDERSLEEVE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10423 CENTURION PKWY N
JACKSONVILLE FL
32256-0527
US

IV. Provider business mailing address

8740 HAMPSHIRE GLEN DR S
JACKSONVILLE FL
32256-9569
US

V. Phone/Fax

Practice location:
  • Phone: 904-854-2093
  • Fax:
Mailing address:
  • Phone: 904-363-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 18915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: