Provider Demographics
NPI:1730666850
Name:NYSTROM, AMANDA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:NYSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:4544 LIVE OAK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-6305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561
Practice Address - Country:US
Practice Address - Phone:850-916-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-21
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL58442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer