Provider Demographics
NPI:1104241520
Name:ELDRIDGE, AMANDA LEE (LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEE
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2423
Mailing Address - Country:US
Mailing Address - Phone:765-592-2319
Mailing Address - Fax:
Practice Address - Street 1:1096 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2423
Practice Address - Country:US
Practice Address - Phone:765-592-2319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001539A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer