Provider Demographics
NPI:1114752888
Name:LIDDY, AMY KAY (FNP-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KAY
Last Name:LIDDY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 SHADOW RUN TRL
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-1267
Mailing Address - Country:US
Mailing Address - Phone:260-403-1093
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4160
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN71015963A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program