Provider Demographics
NPI:1548738610
Name:ALLISON, AMANDA MARIE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:ALLISON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 CITY AVE N
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUE MOUNTAIN
Practice Address - State:MS
Practice Address - Zip Code:38610-9220
Practice Address - Country:US
Practice Address - Phone:662-685-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11002255A2300X
MSAT04172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer