Provider Demographics
NPI:1659712289
Name:JOHNSTON, AMANDA KATHALENE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHALENE
Last Name:JOHNSTON
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 1:201A WATERFORD ST
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2226
Mailing Address - Country:US
Mailing Address - Phone:814-734-5000
Mailing Address - Fax:814-734-1522
Practice Address - Street 1:201A WATERFORD ST
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-2226
Practice Address - Country:US
Practice Address - Phone:814-734-5000
Practice Address - Fax:814-734-1522
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist