Provider Demographics
NPI:1306034962
Name:GENNICK, AMANDA KAE (MSPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAE
Last Name:GENNICK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2138
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5416
Mailing Address - Country:US
Mailing Address - Phone:256-325-5400
Mailing Address - Fax:256-325-5469
Practice Address - Street 1:44 HUGHES RD STE 1050
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2237
Practice Address - Country:US
Practice Address - Phone:256-325-5400
Practice Address - Fax:256-325-5469
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7160485OtherAETNA
AL051543221OtherBCBS
AL510I650037Medicare PIN