Provider Demographics
NPI:1114159100
Name:LARUE, AMANDA NICOLE (PTA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICOLE
Last Name:LARUE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 25TH ST NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3029
Mailing Address - Country:US
Mailing Address - Phone:828-320-6827
Mailing Address - Fax:
Practice Address - Street 1:5901 BROKEN SOUND PKWY STE 500
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2791
Practice Address - Country:US
Practice Address - Phone:800-875-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3719225200000X
TX2070555225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant