Provider Demographics
NPI:1679117477
Name:BURLESON, AMANDA (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 TUMBLIN DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-5325
Mailing Address - Country:US
Mailing Address - Phone:386-690-0984
Mailing Address - Fax:
Practice Address - Street 1:1890 LPGA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7131
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004540363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care