Basic Information
| Provider Information | |||||||||
| NPI: | 1003298969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUTLY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9110768 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | N3KG2 | 01 | FL | BCBSFL | OTHER | 022418500 | 05 | FL | MEDICAID |