Healthcare Provider Details

I. General information

NPI: 1134165921
Provider Name (Legal Business Name): AMANDA DEE MARTIN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PLZ MS 7000
CAPE GIRARDEAU MO
63701-4710
US

IV. Provider business mailing address

2647 TRAVELERS WAY
JACKSON MO
63755-2475
US

V. Phone/Fax

Practice location:
  • Phone: 573-986-6764
  • Fax:
Mailing address:
  • Phone: 405-694-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2006004089
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: