Provider Demographics
NPI:1619615242
Name:LIGHT, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LIGHT
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 1:1147 RIDGEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24263-7825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-2854
Practice Address - Country:US
Practice Address - Phone:276-546-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602874225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant