Provider Demographics
NPI:1588286132
Name:PONCE DE LEON, AMANDA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:PONCE DE LEON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1592
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1592
Mailing Address - Country:US
Mailing Address - Phone:317-373-7882
Mailing Address - Fax:
Practice Address - Street 1:12171 COVERED WAGON CT
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7100
Practice Address - Country:US
Practice Address - Phone:317-373-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013443A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist