Provider Demographics
NPI:1699280412
Name:KEILY, AMANDA LYNN (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:KEILY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-0446
Mailing Address - Country:US
Mailing Address - Phone:760-716-0319
Mailing Address - Fax:
Practice Address - Street 1:1839 HEALTH CARE DR STE 1
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-5363
Practice Address - Country:US
Practice Address - Phone:727-372-0812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0013128225100000X
IDPT-4097225100000X
FLPT-31297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT-31297OtherFLORIDA DEPARTMENT OF HEALTH
IDPT-4097OtherIDAHO DEPT OF HEALTH
COPT-0013128OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES