MEDICARE: MS. AMANDA K VAN VLIET

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN9343112	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013382365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMANDA K VAN VLIET

Provider Business Mailing Address
First Line	:	7406 FULLERTON ST STE 105
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3588
Country	:	US
Telephone Number	:	904-802-6800
Fax Number	:	904-824-2353

Provider Business Practice Location Address
First Line	:	7406 FULLERTON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3552
Country	:	US
Telephone Number	:	904-802-6800
Fax Number	:	904-249-9764

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2015
Last Update Date	:	03/17/2025

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