=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629445002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ANN FULWIDER MA, AT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 COLEMANS XING
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43040-7115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-578-7847
-----------------------------------------------------
Fax | 937-578-7891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11596 LAFAYETTE PLAIN CITY RD
-----------------------------------------------------
City | PLAIN CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43064-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-243-9742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000030605
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT006116
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------