Provider Demographics
NPI:1215186192
Name:PETERSEN, AMANDA WARD (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:WARD
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-2947
Mailing Address - Country:US
Mailing Address - Phone:252-522-1960
Mailing Address - Fax:252-522-3298
Practice Address - Street 1:1610 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-2947
Practice Address - Country:US
Practice Address - Phone:252-522-1960
Practice Address - Fax:252-522-3298
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3854225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant