Basic Information
| Provider Information | |||||||||
| NPI: | 1134572274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITTMER | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6360 TECHSTER BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339664805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392368784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3191 HARBOR BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418834518 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2016 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN9268426 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0200X | APRN9268426 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100028500 | 05 | FL | MEDICAID |