=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003644055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA NICOLE DURRETT FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2024
-----------------------------------------------------
Last Update Date | 07/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14153 YOSEMITE DR STE 104
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-8065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-605-3000
-----------------------------------------------------
Fax | 727-378-4809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 MASON TUCKER DR APT KK295
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37167-5633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-969-6830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11033003
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------