Provider Demographics
NPI:1003298969
Name:OUTLY, AMANDA MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:OUTLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:FAMILY MEDICINE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-6600
Mailing Address - Fax:850-862-0977
Practice Address - Street 1:2001 E. HIGHWAY 20
Practice Address - Street 2:FAMILY MEDICINE DEPARTMENT
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8826
Practice Address - Country:US
Practice Address - Phone:850-897-6600
Practice Address - Fax:850-897-0623
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9110768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN3KG2OtherBCBSFL
FL022418500Medicaid