Provider Demographics
NPI:1245921634
Name:WILLIAMS, AMANDA S (MTI)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MTI
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MTI
Mailing Address - Street 1:250 UPPER PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-1689
Mailing Address - Country:US
Mailing Address - Phone:479-970-4363
Mailing Address - Fax:
Practice Address - Street 1:250 UPPER PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-1689
Practice Address - Country:US
Practice Address - Phone:479-970-4363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist