Provider Demographics
NPI:1427834068
Name:NELSON, AMANDA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:NELSON
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 1:8133 ASPENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-8911
Mailing Address - Country:US
Mailing Address - Phone:443-204-1276
Mailing Address - Fax:
Practice Address - Street 1:6011 UNIVERSITY BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6104
Practice Address - Country:US
Practice Address - Phone:410-203-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant