Provider Demographics
NPI:1558691436
Name:POLK, AMANDA R (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:POLK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:VONRAESFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:34637 AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-8583
Mailing Address - Country:US
Mailing Address - Phone:405-238-7000
Mailing Address - Fax:405-238-7005
Practice Address - Street 1:34637 AIRLINE RD
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-8583
Practice Address - Country:US
Practice Address - Phone:405-238-7000
Practice Address - Fax:405-238-7005
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist