Provider Demographics
NPI:1497808109
Name:STEWART, AMANDA J (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:STEWART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:KEAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12844 COLDWATER RD
Mailing Address - Street 2:STE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8833
Mailing Address - Country:US
Mailing Address - Phone:260-497-7191
Mailing Address - Fax:
Practice Address - Street 1:3805 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-2010
Practice Address - Country:US
Practice Address - Phone:260-497-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016207225100000X
WI10757225100000X
IN05012833A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00727597OtherMEDICARE RR
ILP01055745OtherMEDICARE RAILROAD
ILP01055745OtherMEDICARE RAILROAD
ILIL2993013Medicare PIN
ILP00727597OtherMEDICARE RR
ILR00927Medicare PIN