Provider Demographics
NPI:1881920478
Name:LUCY, AMANDA LYNN (PT DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:LUCY
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 GRAND VISTA LN
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-8912
Mailing Address - Country:US
Mailing Address - Phone:661-400-2951
Mailing Address - Fax:
Practice Address - Street 1:577 E ELDER ST
Practice Address - Street 2:SUITE I
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3079
Practice Address - Country:US
Practice Address - Phone:760-723-2687
Practice Address - Fax:760-723-2689
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01453008OtherRR MEDICARE
CACA113221Medicare PIN
CACB210765Medicare PIN