=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255903316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA JANE SHARP PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2021
-----------------------------------------------------
Last Update Date | 07/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EMORY SPORTS MEDICINE COMPLEX 1968 HAWKS LANE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-778-6330
-----------------------------------------------------
Fax | 404-778-6370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4949 OAKDALE RD SE APT 134
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-7160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-894-4557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT015324
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------