Provider Demographics
NPI:1760281836
Name:DECLERK, AMANDA (ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DECLERK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W 400 N APT 29
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2887
Mailing Address - Country:US
Mailing Address - Phone:515-238-5551
Mailing Address - Fax:
Practice Address - Street 1:3401 N CENTER ST STE 100
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7498
Practice Address - Country:US
Practice Address - Phone:801-753-7770
Practice Address - Fax:801-753-7775
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13525788-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer