Provider Demographics
NPI:1386912897
Name:FLYCKT, AMANDA R (ARNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:FLYCKT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:PMG SW WA PSPH HOSPITALISTS
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-493-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60520308363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041629Medicaid
VT101.0083501OtherAPRN LICENSE