Individual
AMY L BALOG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
661 EYSTER BLVD STE 2, ROCKLEDGE, FL 32955-8119
(321) 806-1874
(321) 806-1875
Mailing address
661 EYSTER BLVD STE 2, ROCKLEDGE, FL 32955-8119
(337) 349-5824
(321) 806-1875
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
609756
NY
363LF0000X
Family Nurse Practitioner
Primary
11010379
FL
363LF0000X
Family Nurse Practitioner
337302
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03457292
—
NY
01
—
120719000037
FIDELIS CARE NY
NY
Enumeration date
04/26/2012
Last updated
10/13/2021
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