Provider Demographics
NPI:1134457831
Name:NELLEMANN, AMANDA WEIGLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:WEIGLE
Last Name:NELLEMANN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:WEIGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:8963 DAYBREAKER DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5819
Mailing Address - Country:US
Mailing Address - Phone:813-446-5257
Mailing Address - Fax:
Practice Address - Street 1:8TH AVE C ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-4220
Practice Address - Country:US
Practice Address - Phone:801-408-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 13076225X00000X
TX113212225X00000X
NC7261225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist