Provider Demographics
NPI:1629445002
Name:FULWIDER, AMANDA ANN (MA, AT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ANN
Last Name:FULWIDER
Suffix:
Gender:F
Credentials:MA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11596 LAFAYETTE PLAIN CITY RD
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-9010
Mailing Address - Country:US
Mailing Address - Phone:937-243-9742
Mailing Address - Fax:
Practice Address - Street 1:120 COLEMANS XING
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-7115
Practice Address - Country:US
Practice Address - Phone:937-578-7847
Practice Address - Fax:937-578-7891
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000306052255A2300X
390200000X
OHAT0061162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT006116OtherATHLETIC TRAINER