Provider Demographics
NPI:1346541927
Name:VAN LIESSUM, AMANDA LEIGH (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEIGH
Last Name:VAN LIESSUM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:440 N STATE ROAD 7
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-3504
Mailing Address - Country:US
Mailing Address - Phone:561-795-8655
Mailing Address - Fax:561-795-8449
Practice Address - Street 1:440 N STATE ROAD 7
Practice Address - Street 2:SUITE 107
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3504
Practice Address - Country:US
Practice Address - Phone:561-795-8655
Practice Address - Fax:561-795-8449
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9265531363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner