Healthcare Provider Details

I. General information

NPI: 1114159100
Provider Name (Legal Business Name): AMANDA NICOLE LARUE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 08/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 BROKEN SOUND PKWY STE 500
BOCA RATON FL
33487-2791
US

IV. Provider business mailing address

1055 25TH ST NE
HICKORY NC
28601-3029
US

V. Phone/Fax

Practice location:
  • Phone: 800-875-8999
  • Fax:
Mailing address:
  • Phone: 828-320-6827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3719
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2070555
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: