Provider Demographics
NPI:1457740185
Name:CALCOTE, AMY DIANE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DIANE
Last Name:CALCOTE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DIANE
Other - Last Name:GULLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2673 FOX CREEK DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-2895
Mailing Address - Country:US
Mailing Address - Phone:904-507-1003
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9288726367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014324700Medicaid
GA003158359AMedicaid
FL014324700Medicaid
FLIB641ZMedicare PIN