Provider Demographics
NPI:1467463083
Name:WALRATH, AMANDA L (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WALRATH
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 1:2462 JOHNSON STREET RD
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-9736
Mailing Address - Country:US
Mailing Address - Phone:319-524-1041
Mailing Address - Fax:319-524-1041
Practice Address - Street 1:2462 JOHNSON STREET RD
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-9736
Practice Address - Country:US
Practice Address - Phone:319-524-1041
Practice Address - Fax:319-524-1041
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03212225100000X
MO112711225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003432008OtherBCBS PRIVIDER NUMBER