Provider Demographics
NPI:1629556410
Name:HARRELL, AMANDA LYNNE (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNNE
Last Name:HARRELL
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 1:19293 NW 230TH ST
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-4157
Mailing Address - Country:US
Mailing Address - Phone:352-339-3538
Mailing Address - Fax:
Practice Address - Street 1:1438 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1106
Practice Address - Country:US
Practice Address - Phone:386-755-3164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28364225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant