Provider Demographics
NPI:1336807130
Name:KERLIN, AMANDA MARIE (CRDH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:KERLIN
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRDH
Mailing Address - Street 1:1153 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-3213
Mailing Address - Country:US
Mailing Address - Phone:904-514-0504
Mailing Address - Fax:
Practice Address - Street 1:2104 MASSEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:904-270-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22914124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist