Provider Demographics
NPI:1093357576
Name:COOMES, AMANDA JEAN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:COOMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6641 SPRING HAVEN TRCE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-8048
Mailing Address - Country:US
Mailing Address - Phone:270-903-7390
Mailing Address - Fax:
Practice Address - Street 1:6641 SPRING HAVEN TRCE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-8048
Practice Address - Country:US
Practice Address - Phone:270-903-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist