Provider Demographics
NPI:1124795802
Name:RUSSELL, AMANDA DIDAWICK
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIDAWICK
Last Name:RUSSELL
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 1:4602 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-2412
Mailing Address - Country:US
Mailing Address - Phone:910-423-5622
Mailing Address - Fax:910-378-1755
Practice Address - Street 1:103 SLEEPY DR STE G
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3319
Practice Address - Country:US
Practice Address - Phone:910-423-5622
Practice Address - Fax:910-378-1755
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist