Provider Demographics
NPI:1669721155
Name:PEACOCK, AMANDA B (ACNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-345-7776
Mailing Address - Fax:904-345-7772
Practice Address - Street 1:3 SHIRCLIFF WAY
Practice Address - Street 2:SUITE 714
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4757
Practice Address - Country:US
Practice Address - Phone:904-308-2006
Practice Address - Fax:904-308-7111
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9349014363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01118046OtherRAILROAD MEDICARE
FLY0E3SOtherBCBS-FL
FLGS830ZMedicare PIN