Provider Demographics
NPI:1992249619
Name:MARTIN, AMANDA L (MS, ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, ATC
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 232
Mailing Address - Street 2:
Mailing Address - City:EAST THETFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05043-0232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 OLD HOMESTEAD HWY
Practice Address - Street 2:
Practice Address - City:SWANZEY
Practice Address - State:NH
Practice Address - Zip Code:03446-2301
Practice Address - Country:US
Practice Address - Phone:603-352-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13052255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer