Provider Demographics
NPI:1134572274
Name:DITTMER, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DITTMER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 TECHSTER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4805
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:
Practice Address - Street 1:3191 HARBOR BLVD STE B
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6755
Practice Address - Country:US
Practice Address - Phone:941-883-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9268426363LP0808X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100028500Medicaid