Provider Demographics
NPI:1174586432
Name:LIGHTSEY, AMANDA JEAN (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:LIGHTSEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 BOONVILLE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-2334
Mailing Address - Country:US
Mailing Address - Phone:979-446-0422
Mailing Address - Fax:
Practice Address - Street 1:2651 BOONVILLE RD STE 115
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77808-2334
Practice Address - Country:US
Practice Address - Phone:979-446-0422
Practice Address - Fax:979-446-0433
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1145365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T2272OtherBLUE SHIELD
TX1651572-02Medicaid
TX1651572-02Medicaid