Provider Demographics
NPI:1558489468
Name:PIPPINGER, AMANDA SUE (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:PIPPINGER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 STILLWATER DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9119
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:870-932-3611
Practice Address - Street 1:1900 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9119
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:870-932-3611
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2059225200000X
AROTR2532225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157415721Medicaid