Provider Demographics
NPI:1295231389
Name:NUGALIYADDA, AMANDA JAYASHKI (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JAYASHKI
Last Name:NUGALIYADDA
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 1:18444 N 25TH AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1264
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-974-2673
Practice Address - Street 1:22250 PROVIDENCE DR STE 405
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6212
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005497225200000X
MI5501303372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant