Healthcare Provider Details

I. General information

NPI: 1174175285
Provider Name (Legal Business Name): AMANDA KAY GRAHAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

IV. Provider business mailing address

1222 S ORANGE AVE
ORLANDO FL
32806-1215
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7856
  • Fax: 321-843-6432
Mailing address:
  • Phone: 321-841-7856
  • Fax: 321-843-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11002696
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11002696
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number9375941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: