Provider Demographics
NPI:1720375645
Name:YOACHUM, AMANDA LANE (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LANE
Last Name:YOACHUM
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 1:5378 WANDERING TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-2718
Mailing Address - Country:US
Mailing Address - Phone:904-476-0258
Mailing Address - Fax:904-213-9806
Practice Address - Street 1:155-8 BLANDING BLVD.
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-476-0258
Practice Address - Fax:904-213-9806
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50836225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist