Provider Demographics
NPI:1689813305
Name:PHILLIPS, AMANDA (FNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 WINGATE TRL
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7524
Mailing Address - Country:US
Mailing Address - Phone:386-846-7524
Mailing Address - Fax:386-423-2525
Practice Address - Street 1:420 STADIUM RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2400
Practice Address - Country:US
Practice Address - Phone:386-236-1780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000013916363LF0000X
FLAPRN9329067363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health