Provider Demographics
NPI:1891852604
Name:SMITH, AMANDA L (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 GARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3387
Mailing Address - Country:US
Mailing Address - Phone:941-894-2956
Mailing Address - Fax:
Practice Address - Street 1:516 GARDEN WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3387
Practice Address - Country:US
Practice Address - Phone:941-894-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23094225100000X
KY007495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAE321ZOtherMEDICARE ID TYPE