Provider Demographics
NPI:1508905795
Name:DIERKING, AMANDA COLETTE
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:COLETTE
Last Name:DIERKING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11303 CROWNE BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-1660
Mailing Address - Country:US
Mailing Address - Phone:615-390-7754
Mailing Address - Fax:
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-540-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000003969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant