=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750037313
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY ELIZABETH BEACH FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2022
-----------------------------------------------------
Last Update Date | 05/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E ASH ST
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32347-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-584-3278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 OHIO AVE S
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32064-4146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-339-1060
-----------------------------------------------------
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 | APRN11018407
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------