Provider Demographics
NPI:1841857125
Name:KNUTSON, AMBER HOPE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:HOPE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:HOPE
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5727 DUSKY RUN
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-2920
Mailing Address - Country:US
Mailing Address - Phone:317-488-8459
Mailing Address - Fax:
Practice Address - Street 1:640 BREVARD AVE STE 104
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7849
Practice Address - Country:US
Practice Address - Phone:317-488-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1346353067Medicaid