Healthcare Provider Details

I. General information

NPI: 1992249619
Provider Name (Legal Business Name): AMANDA L. MARTIN MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 OLD HOMESTEAD HWY
SWANZEY NH
03446-2301
US

IV. Provider business mailing address

PO BOX 232
EAST THETFORD VT
05043-0232
US

V. Phone/Fax

Practice location:
  • Phone: 603-352-6955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1305
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: