Provider Demographics
NPI:1053062109
Name:D'AMICO, HEATHER ANN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:D'AMICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12759 RIVER STORY CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2401
Mailing Address - Country:US
Mailing Address - Phone:904-887-6433
Mailing Address - Fax:
Practice Address - Street 1:12759 RIVER STORY CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2401
Practice Address - Country:US
Practice Address - Phone:904-887-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017365363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner