Provider Demographics
NPI:1881863652
Name:GRAHAM, AMANDA KRISTEN (ARNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KRISTEN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KRISTEN
Other - Last Name:KLIPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:27 MARCO ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0532
Mailing Address - Country:US
Mailing Address - Phone:904-616-0322
Mailing Address - Fax:
Practice Address - Street 1:425 N LEE ST STE 203
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1128
Practice Address - Country:US
Practice Address - Phone:904-354-8200
Practice Address - Fax:904-354-1340
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9201902363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308972000Medicaid
FLAJ350ZMedicare PIN