Provider Demographics
NPI:1588033450
Name:FORMYDUVAL, AMY LANDIS
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LANDIS
Last Name:FORMYDUVAL
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 1:6404 SPICEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-7756
Mailing Address - Country:US
Mailing Address - Phone:910-840-6802
Mailing Address - Fax:
Practice Address - Street 1:6404 SPICEWOOD ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-7756
Practice Address - Country:US
Practice Address - Phone:910-840-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC203176367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered