Provider Demographics
NPI:1003649633
Name:KANE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 N VAN DORN ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1914
Mailing Address - Country:US
Mailing Address - Phone:717-870-5759
Mailing Address - Fax:
Practice Address - Street 1:5000 FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1246
Practice Address - Country:US
Practice Address - Phone:717-870-5759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003770225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist