Provider Demographics
NPI:1346360005
Name:HAGAN, AMANDA L (PT)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:L
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 BURLINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8628
Mailing Address - Country:US
Mailing Address - Phone:859-640-5039
Mailing Address - Fax:
Practice Address - Street 1:3011 BURLINGTON AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8628
Practice Address - Country:US
Practice Address - Phone:859-640-5039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL245522251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics