Provider Demographics
NPI:1063744944
Name:SHARP, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:SHARP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST. SE
Mailing Address - Street 2:MMC 388
Mailing Address - City:MINNEAPOLS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-4601
Mailing Address - Fax:
Practice Address - Street 1:164 PILLSBURY DR SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0279
Practice Address - Country:US
Practice Address - Phone:612-624-3322
Practice Address - Fax:612-624-7586
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11145-24225100000X
MN8981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty