Provider Demographics
NPI:1144622945
Name:LANGE, AMANDA SHARON (LMT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SHARON
Last Name:LANGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 VISTA PALM DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-5513
Mailing Address - Country:US
Mailing Address - Phone:386-314-0227
Mailing Address - Fax:
Practice Address - Street 1:315 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1617
Practice Address - Country:US
Practice Address - Phone:386-427-8403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA34247225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist