Provider Demographics
NPI:1083765499
Name:AMIS, SHARON LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LOUISE
Last Name:AMIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9543
Mailing Address - Country:US
Mailing Address - Phone:574-825-8118
Mailing Address - Fax:574-822-1169
Practice Address - Street 1:611 WAYNE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9543
Practice Address - Country:US
Practice Address - Phone:574-825-8118
Practice Address - Fax:574-822-1169
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006720A225100000X
MI5501006973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN181350AMedicare ID - Type UnspecifiedMEDICARE P.T.