Provider Demographics
NPI:1417295577
Name:EDWARDS, AMANDA PAIGE (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:PAIGE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:PAIGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:234 WEST STREET SOUTH
Mailing Address - Street 2:SOUTHVIEW PLAZA SUITE #4
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-9998
Mailing Address - Country:US
Mailing Address - Phone:641-236-4506
Mailing Address - Fax:641-236-4316
Practice Address - Street 1:234 WEST STREET SOUTH
Practice Address - Street 2:SOUTHVIEW PLAZA SUITE #4
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-9998
Practice Address - Country:US
Practice Address - Phone:641-236-4506
Practice Address - Fax:641-236-4316
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005091208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14912Medicare PIN