Healthcare Provider Details

I. General information

NPI: 1255675229
Provider Name (Legal Business Name): AMANDA B DORNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA B CARLILE

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 E CEDAR AVE STE A
CRESTVIEW FL
32539-2860
US

IV. Provider business mailing address

521 E CEDAR AVE STE A
CRESTVIEW FL
32539-2860
US

V. Phone/Fax

Practice location:
  • Phone: 850-331-3017
  • Fax: 850-331-6635
Mailing address:
  • Phone: 850-331-3017
  • Fax: 850-331-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0913
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: