Basic Information
| Provider Information | |||||||||
| NPI: | 1366616898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEMING | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANLEY | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1807 | ||||||||
| Address2: | |||||||||
| City: | GATE CITY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763862424 | ||||||||
| FaxNumber: | 2763861446 | ||||||||
| Practice Location | |||||||||
| Address1: | 389 KANE STREET | ||||||||
| Address2: | |||||||||
| City: | GATE CITY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763862424 | ||||||||
| FaxNumber: | 2763862349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305204535 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QR0401X | 2305204535 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 225100000X | 6604 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004979681 | 05 | VA | MEDICAID | 4979681 | 05 | VA | MEDICAID |