Provider Demographics
NPI:1104445113
Name:BRENNER, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5148
Mailing Address - Country:US
Mailing Address - Phone:904-639-2000
Mailing Address - Fax:904-639-2015
Practice Address - Street 1:2436 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2002
Practice Address - Country:US
Practice Address - Phone:904-916-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME158502207QG0300X, 207Q00000X, 208100000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist