Provider Demographics
NPI:1053711788
Name:MACLEAN, AMY ELIZABETH (ARNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:MACLEAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4866 BIG ISLAND DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7498
Mailing Address - Country:US
Mailing Address - Phone:904-652-0652
Mailing Address - Fax:
Practice Address - Street 1:4866 BIG ISLAND DR
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7498
Practice Address - Country:US
Practice Address - Phone:904-652-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9168850363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014677300Medicaid
FLID347ZMedicare PIN