Provider Demographics
NPI:1902514573
Name:OUTLER, AMANDA LEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:OUTLER
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 1:1801 TINDEL CAMP RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-7537
Mailing Address - Country:US
Mailing Address - Phone:863-287-6925
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022566363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily