Provider Demographics
NPI:1275092603
Name:WILLGING, AMANDA (ATC, OTC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILLGING
Suffix:
Gender:F
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 FADING STAR CT
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-2056
Mailing Address - Country:US
Mailing Address - Phone:540-684-0951
Mailing Address - Fax:
Practice Address - Street 1:19455 DEERFIELD AVE STE 306
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8102
Practice Address - Country:US
Practice Address - Phone:703-729-5010
Practice Address - Fax:703-729-5833
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260022992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer