Provider Demographics
NPI:1316537756
Name:YATABE, AMANDA JON MCNALLY (ARNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JON MCNALLY
Last Name:YATABE
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 1:400 E SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3184
Mailing Address - Country:US
Mailing Address - Phone:321-722-5200
Mailing Address - Fax:
Practice Address - Street 1:400 E SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3184
Practice Address - Country:US
Practice Address - Phone:321-722-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011170363L00000X
FLAPRN11011170101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner