Healthcare Provider Details

I. General information

NPI: 1467267443
Provider Name (Legal Business Name): AMANDA ELY RRA/RPA, RT(R)(CT)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2025
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

75297 SEMPER FI DR
YULEE FL
32097-1704
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-0411
  • Fax:
Mailing address:
  • Phone: 904-657-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License NumberCRT85880
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA179
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number25RRAFL0222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: