Provider Demographics
NPI:1295576783
Name:MAMBOURG, AMANDA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MAMBOURG
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:HARTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:5995 WILCOX PL STE E
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-9267
Mailing Address - Country:US
Mailing Address - Phone:614-689-2103
Mailing Address - Fax:614-689-2105
Practice Address - Street 1:5995 WILCOX PL STE E
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-9267
Practice Address - Country:US
Practice Address - Phone:614-689-2103
Practice Address - Fax:614-689-2105
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist