MEDICARE: MRS. AMANDA MICHELLE BURNS

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	363A00000X	Physician Assistant	PA9116653	FL

General Provider Information

NPI Number	:	1255004149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA MICHELLE BURNS

Provider Business Mailing Address
First Line	:	6922 SINGLETARY ST
Second Line	:
City	:	GRAND RIDGE
State	:	FL
Zip	:	32442-8901
Country	:	US
Telephone Number	:	850-510-1147
Fax Number	:

Provider Business Practice Location Address
First Line	:	6922 SINGLETARY ST
Second Line	:
City	:	GRAND RIDGE
State	:	FL
Zip	:	32442-8901
Country	:	US
Telephone Number	:	850-510-1147
Fax Number	:

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

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	02/27/2024

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