Provider Demographics
NPI:1811364300
Name:DE LA FUENTE, AMY N (ARNP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:N
Last Name:DE LA FUENTE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:DETTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:913 MALL RING ROAD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-8075
Mailing Address - Country:US
Mailing Address - Phone:863-304-8038
Mailing Address - Fax:863-304-8035
Practice Address - Street 1:931 MALL RING RD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-8515
Practice Address - Country:US
Practice Address - Phone:863-304-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9327671363LF0000X, 363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMDXDEOtherBLUE CROSS BLUE SHEILD
FL832148721Medicaid