Basic Information
Provider Information
NPI: 1003298969
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OUTLY
FirstName: AMANDA
MiddleName: MICHELLE
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1005 MAR WALT DRIVE
Address2: FAMILY MEDICINE DEPARTMENT
City: FORT WALTON BEACH
State: FL
PostalCode: 325476796
CountryCode: US
TelephoneNumber: 8508636600
FaxNumber: 8508620977
Practice Location
Address1: 2001 E. HIGHWAY 20
Address2: FAMILY MEDICINE DEPARTMENT
City: NICEVILLE
State: FL
PostalCode: 325788826
CountryCode: US
TelephoneNumber: 8508976600
FaxNumber: 8508970623
Other Information
ProviderEnumerationDate: 06/26/2015
LastUpdateDate: 01/17/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA9110768FLY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
02241850005FL MEDICAID
N3KG201FLBCBSFLOTHER


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