Basic Information
| Provider Information | |||||||||
| NPI: | 1689893976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAVY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GULKA | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT, CSCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 S 11TH ST; STE 1000-CENTER FOR PREVENTION & GENETI | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017807620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1429 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.