Basic Information
| Provider Information | |||||||||
| NPI: | 1720346869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALOG | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 661 EYSTER BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329558119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373495824 | ||||||||
| FaxNumber: | 3218061875 | ||||||||
| Practice Location | |||||||||
| Address1: | 661 EYSTER BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329558119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218061874 | ||||||||
| FaxNumber: | 3218061875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 609756 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 337302 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 11010379 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03457292 | 05 | NY | MEDICAID | 120719000037 | 01 | NY | FIDELIS CARE NY | OTHER |