Provider Demographics
NPI:1881020204
Name:WELKER, AMANDA (LPTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WELKER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5247 US ROUTE 224
Mailing Address - Street 2:
Mailing Address - City:CONVOY
Mailing Address - State:OH
Mailing Address - Zip Code:45832-8923
Mailing Address - Country:US
Mailing Address - Phone:419-203-0403
Mailing Address - Fax:
Practice Address - Street 1:1717 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7656
Practice Address - Country:US
Practice Address - Phone:855-202-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004735A225200000X
OHPTA.09127225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant