Provider Demographics
NPI:1013382365
Name:VAN VLIET, AMANDA K
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:K
Last Name:VAN VLIET
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 FULLERTON ST STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3588
Mailing Address - Country:US
Mailing Address - Phone:904-802-6800
Mailing Address - Fax:904-824-2353
Practice Address - Street 1:7406 FULLERTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3552
Practice Address - Country:US
Practice Address - Phone:904-802-6800
Practice Address - Fax:904-249-9764
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9343112363L00000X
FL9343112363LF0000X
FLARNP9313112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily