Provider Demographics
NPI:1821386376
Name:DUDEK, AMANDA JEAN (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:DUDEK
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SHAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9328 E OLLA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1400
Mailing Address - Country:US
Mailing Address - Phone:602-736-1104
Mailing Address - Fax:
Practice Address - Street 1:9385 W DONALD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2988
Practice Address - Country:US
Practice Address - Phone:602-875-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9403PT2251P0200X
AZLPT-009403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics