Healthcare Provider Details

I. General information

NPI: 1720346869
Provider Name (Legal Business Name): AMY L BALOG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 EYSTER BLVD STE 2
ROCKLEDGE FL
32955-8119
US

IV. Provider business mailing address

661 EYSTER BLVD STE 2
ROCKLEDGE FL
32955-8119
US

V. Phone/Fax

Practice location:
  • Phone: 321-806-1874
  • Fax: 321-806-1875
Mailing address:
  • Phone: 337-349-5824
  • Fax: 321-806-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number609756
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337302
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11010379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: