Healthcare Provider Details

I. General information

NPI: 1740781434
Provider Name (Legal Business Name): AMANDA MATTINGLY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 BLOOMFIELD RD
BARDSTOWN KY
40004-2025
US

IV. Provider business mailing address

107 WESTWIND TRL
BARDSTOWN KY
40004-1827
US

V. Phone/Fax

Practice location:
  • Phone: 502-331-5478
  • Fax: 502-385-0234
Mailing address:
  • Phone: 502-741-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number006385
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: