Provider Demographics
NPI:1437781622
Name:KELLY, AMANDA LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:KELLY
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 1:4246 W SAW BLADE LN APT 102
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-0022
Mailing Address - Country:US
Mailing Address - Phone:208-731-9528
Mailing Address - Fax:
Practice Address - Street 1:411 W HAYCRAFT AVE # STDD1
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8105
Practice Address - Country:US
Practice Address - Phone:208-664-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT6569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist