Provider Demographics
NPI:1962867838
Name:BENNETT, AMANDA (ATC, LAT, PES, EMT-B)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ATC, LAT, PES, EMT-B
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BAYLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LAT, PES, EMT-B
Mailing Address - Street 1:705 CENTRAL PARKE CIR APT 208
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-9590
Mailing Address - Country:US
Mailing Address - Phone:865-556-9589
Mailing Address - Fax:
Practice Address - Street 1:705 CENTRAL PARKE CIR APT 208
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-9590
Practice Address - Country:US
Practice Address - Phone:865-556-9589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL3539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist