Provider Demographics
NPI:1528462215
Name:FULENWIDER, AMANDA HEDGES (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:HEDGES
Last Name:FULENWIDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 PARK ROWE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1685
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:833-756-2680
Practice Address - Street 1:15420 S HARRELLS FERRY RD STE D
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2933
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:833-756-2680
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA375990YJ6VMedicare PIN