Basic Information
| Provider Information | |||||||||
| NPI: | 1053748202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | MANAGE CARE DEPT | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3525 LAKELAND HILLS BLVD | ||||||||
| Address2: | LAKELAND REGIONAL CANCER CENTER | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636036565 | ||||||||
| FaxNumber: | 8639041969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9242327 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.