Provider Demographics
NPI:1396065694
Name:DIMITRIADES, AMY M (NP-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:DIMITRIADES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:228-865-1331
Practice Address - Street 1:4540 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2480
Practice Address - Country:US
Practice Address - Phone:228-867-6062
Practice Address - Fax:228-867-2598
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR859046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily