Provider Demographics
NPI:1689444945
Name:MCNULTY, AMANDA (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-3530
Mailing Address - Country:US
Mailing Address - Phone:631-935-3403
Mailing Address - Fax:
Practice Address - Street 1:1850 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6012
Practice Address - Country:US
Practice Address - Phone:631-886-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029230225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist