Provider Demographics
NPI:1235187337
Name:WOLF, AMANDA CAROL (ATC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:CAROL
Last Name:WOLF
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-1150
Mailing Address - Country:US
Mailing Address - Phone:417-673-5123
Mailing Address - Fax:
Practice Address - Street 1:3950 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1512
Practice Address - Country:US
Practice Address - Phone:417-625-3174
Practice Address - Fax:417-625-3134
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040107902255A2300X
KS24-003132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer