Healthcare Provider Details

I. General information

NPI: 1548640196
Provider Name (Legal Business Name): AMY JENELLE LASH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 MAHAN CENTER BLVD
TALLAHASSEE FL
32308-5427
US

IV. Provider business mailing address

PO BOX 13859
TALLAHASSEE FL
32317-3859
US

V. Phone/Fax

Practice location:
  • Phone: 850-205-6232
  • Fax: 850-402-9130
Mailing address:
  • Phone: 850-877-4134
  • Fax: 850-402-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9108741
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: