Provider Demographics
NPI:1366616898
Name:FLEMING, AMANDA LEE (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:FLEMING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1807
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251
Mailing Address - Country:US
Mailing Address - Phone:276-386-2424
Mailing Address - Fax:276-386-1446
Practice Address - Street 1:389 KANE STREET
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251
Practice Address - Country:US
Practice Address - Phone:276-386-2424
Practice Address - Fax:276-386-2349
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204535225100000X, 261QR0401X
TN6604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004979681Medicaid
VA4979681Medicaid