Provider Demographics
NPI:1083252662
Name:BOFENKAMP, AMY LYN (AMY)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYN
Last Name:BOFENKAMP
Suffix:
Gender:F
Credentials:AMY
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYN
Other - Last Name:BOFENKAMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMBT
Mailing Address - Street 1:517 BROOKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6104
Mailing Address - Country:US
Mailing Address - Phone:336-391-7276
Mailing Address - Fax:
Practice Address - Street 1:517 BROOKRIDGE DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6104
Practice Address - Country:US
Practice Address - Phone:336-391-7276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10625225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist