Provider Demographics
NPI:1902475015
Name:BENNETT, AMANDA MARIE
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 COLLEY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2508
Mailing Address - Country:US
Mailing Address - Phone:757-620-5464
Mailing Address - Fax:757-799-1668
Practice Address - Street 1:4210 COLLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2508
Practice Address - Country:US
Practice Address - Phone:757-620-5464
Practice Address - Fax:757-799-1668
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA230521125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist