Provider Demographics
NPI:1679174668
Name:THOMAS, AMANDA L
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65458
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-0008
Mailing Address - Country:US
Mailing Address - Phone:850-225-9494
Mailing Address - Fax:
Practice Address - Street 1:50 N LAURA ST STE 2500
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3220
Practice Address - Country:US
Practice Address - Phone:904-478-8300
Practice Address - Fax:904-478-8301
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL236816253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL801724Medicaid