Healthcare Provider Details

I. General information

NPI: 1629445002
Provider Name (Legal Business Name): AMANDA ANN FULWIDER MA, AT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COLEMANS XING
MARYSVILLE OH
43040-7115
US

IV. Provider business mailing address

11596 LAFAYETTE PLAIN CITY RD
PLAIN CITY OH
43064-9010
US

V. Phone/Fax

Practice location:
  • Phone: 937-578-7847
  • Fax: 937-578-7891
Mailing address:
  • Phone: 937-243-9742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000030605
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT006116
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: