Provider Demographics
NPI:1083687875
Name:WILLINGHAM, AMY RENEE (PHYSICALTHERAPISTMPT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:RENEE
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:PHYSICALTHERAPISTMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16827 INTERLACHEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4639
Mailing Address - Country:US
Mailing Address - Phone:952-431-6341
Mailing Address - Fax:
Practice Address - Street 1:1620 17TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2839
Practice Address - Country:US
Practice Address - Phone:507-332-2204
Practice Address - Fax:507-332-2270
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP41242OtherHEALTH PARTNERS PROV #
MN236065OtherARAZ PROVIDER #
MN6402283OtherMEDICA INDIVIDUAL PROV #
MN110J8WIOtherBCBS IND PROVIDER #
MN116113OtherU-CARE PROVIDER #