Provider Demographics
NPI:1073669792
Name:LARUE, AMANDA MARIE (ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIE
Last Name:LARUE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 FOX RD APT 8
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-3356
Mailing Address - Country:US
Mailing Address - Phone:214-293-5834
Mailing Address - Fax:
Practice Address - Street 1:800 UNIVERSITY DR
Practice Address - Street 2:LAMKIN ACTIVITY CENTER
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-6015
Practice Address - Country:US
Practice Address - Phone:660-562-1664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer