Healthcare Provider Details

I. General information

NPI: 1700271517
Provider Name (Legal Business Name): AMANDA IVEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 W YELLOWJACKET LN
ROCKWALL TX
75087-4950
US

IV. Provider business mailing address

3001 SPRING FOREST RD
RALEIGH NC
27616-2815
US

V. Phone/Fax

Practice location:
  • Phone: 866-584-7117
  • Fax:
Mailing address:
  • Phone: 919-424-5086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2109018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: