Provider Demographics
NPI:1396020897
Name:VAN EVERA, AMANDA ELLNEN (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELLNEN
Last Name:VAN EVERA
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 1:37 MITCHELL CIR
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9124
Mailing Address - Country:US
Mailing Address - Phone:870-213-5402
Mailing Address - Fax:
Practice Address - Street 1:37 MITCHELL CIR
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058-9124
Practice Address - Country:US
Practice Address - Phone:870-213-5402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1937225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant