Provider Demographics
NPI:1063084341
Name:CHAMPAGNE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CHAMPAGNE
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:N2860 S 11TH RD
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:WI
Mailing Address - Zip Code:54112-9426
Mailing Address - Country:US
Mailing Address - Phone:920-373-0932
Mailing Address - Fax:
Practice Address - Street 1:501 2ND ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3203
Practice Address - Country:US
Practice Address - Phone:906-863-9941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant