Provider Demographics
NPI:1013382365
Name:VAN VLIET, AMANDA K (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:K
Last Name:VAN VLIET
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 SOUTHPARK CIR E
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5135
Mailing Address - Country:US
Mailing Address - Phone:904-824-2201
Mailing Address - Fax:904-824-2353
Practice Address - Street 1:1370 13TH AVE S STE 215
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-249-1041
Practice Address - Fax:904-249-9764
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9343112163W00000X, 363LF0000X
FLARNP9313112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily