Provider Demographics
NPI:1942648506
Name:KENYON, AMANDA GRACE (OTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:KENYON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3708
Mailing Address - Country:US
Mailing Address - Phone:321-298-1856
Mailing Address - Fax:
Practice Address - Street 1:33 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3708
Practice Address - Country:US
Practice Address - Phone:321-298-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12444224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant