Provider Demographics
NPI:1104853241
Name:FRASER, AMY JOHNSTON (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JOHNSTON
Last Name:FRASER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 CENTENNIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0588
Mailing Address - Country:US
Mailing Address - Phone:850-877-8539
Mailing Address - Fax:850-877-6674
Practice Address - Street 1:2631 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0588
Practice Address - Country:US
Practice Address - Phone:850-877-8539
Practice Address - Fax:850-877-6674
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9202410363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ68901Medicare UPIN
U7301ZMedicare PIN