MEDICARE: AMANDA JEAN LIGHTSEY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1145365	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8T2272	OTHER	TX	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174586432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JEAN LIGHTSEY PT

Provider Business Mailing Address
First Line	:	2651 BOONVILLE RD STE 115
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77808-2334
Country	:	US
Telephone Number	:	979-446-0422
Fax Number	:

Provider Business Practice Location Address
First Line	:	2651 BOONVILLE RD STE 115
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77808-2334
Country	:	US
Telephone Number	:	979-446-0422
Fax Number	:	979-446-0433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	06/28/2016

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