Provider Demographics
NPI:1467909242
Name:WATSON, AMANDA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9706 KINGSTON LN
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-8181
Mailing Address - Country:US
Mailing Address - Phone:918-961-1488
Mailing Address - Fax:
Practice Address - Street 1:1820 WARREN AVE # 89
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-1937
Practice Address - Country:US
Practice Address - Phone:918-961-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24010332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer