Basic Information
| Provider Information | |||||||||
| NPI: | 1205381241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAKEMAN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOCKE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E YOUNG AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | WARRENSBURG | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640931231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602624795 | ||||||||
| FaxNumber: | 6607470347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2016 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2016027664 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.