Provider Demographics
NPI:1043612260
Name:BURGESS, AMY MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:BURGESS
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 1:1901 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2554
Mailing Address - Country:US
Mailing Address - Phone:952-250-9918
Mailing Address - Fax:
Practice Address - Street 1:1901 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:952-250-9918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer