Provider Demographics
NPI:1730666850
Name:NYSTROM, AMANDA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:NYSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:174 ALLEGIANCE ST
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1420
Practice Address - Country:US
Practice Address - Phone:910-630-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-21
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL58442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer