Provider Demographics
NPI:1770892655
Name:MAYFIELD, AMANDA FAY
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:FAY
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:MAYFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1055 SOUTHGATE DR.
Mailing Address - Street 2:
Mailing Address - City:MACEO
Mailing Address - State:KY
Mailing Address - Zip Code:42355
Mailing Address - Country:US
Mailing Address - Phone:270-315-9004
Mailing Address - Fax:
Practice Address - Street 1:1055 SOUTHGATE DR
Practice Address - Street 2:
Practice Address - City:MACEO
Practice Address - State:KY
Practice Address - Zip Code:42355-9731
Practice Address - Country:US
Practice Address - Phone:270-315-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR93116251222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist