Basic Information
| Provider Information | |||||||||
| NPI: | 1669721155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEACOCK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457776 | ||||||||
| FaxNumber: | 9043457772 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SHIRCLIFF WAY | ||||||||
| Address2: | SUITE 714 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043082006 | ||||||||
| FaxNumber: | 9043087111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2012 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 9349014 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | P01118046 | 01 | FL | RAILROAD MEDICARE | OTHER | Y0E3S | 01 | FL | BCBS-FL | OTHER |