Provider Demographics
NPI:1376808881
Name:CARNINE, AMANDA LEE (DPT)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LEE
Last Name:CARNINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2700
Mailing Address - Country:US
Mailing Address - Phone:541-567-5678
Mailing Address - Fax:541-567-2110
Practice Address - Street 1:1050 W ELM AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2700
Practice Address - Country:US
Practice Address - Phone:541-567-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist