Provider Demographics
NPI:1619691409
Name:SORRELLS, AMANDA 3046451706
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:3046451706
Last Name:SORRELLS
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 1:10434 SENECA TRL S
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1586
Mailing Address - Country:US
Mailing Address - Phone:304-667-5401
Mailing Address - Fax:
Practice Address - Street 1:10434 SENECA TRL S
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1586
Practice Address - Country:US
Practice Address - Phone:304-667-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001757225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant