Healthcare Provider Details

I. General information

NPI: 1386912897
Provider Name (Legal Business Name): AMANDA R FLYCKT ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 LILLY RD NE PMG SW WA PSPH HOSPITALISTS
OLYMPIA WA
98506-5133
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-4069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60520308
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: