MEDICARE: AMANDA ALISE FIERGE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	5683	TN

General Provider Information

NPI Number	:	1497168322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ALISE FIERGE PTA

Provider Business Mailing Address
First Line	:	2485 FORT CAMPBELL BLVD
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042-7787
Country	:	US
Telephone Number	:	931-241-4391
Fax Number	:

Provider Business Practice Location Address
First Line	:	2485 FORT CAMPBELL BLVD
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042-7787
Country	:	US
Telephone Number	:	931-241-4391
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/09/2014

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