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:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-848-0629
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:880 SW 145TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6166
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0037832363LA2200X
KY4029272363LA2200X
AZ316040363LA2200X
FLARNP9327671363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL832148721Medicaid
FLMDXDEOtherBLUE CROSS BLUE SHEILD