Provider Demographics
NPI:1104038322
Name:NISTICO, AMY EASTERLY (MOT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:EASTERLY
Last Name:NISTICO
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 NW 9TH ST
Practice Address - Street 2:SUITE180
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6173
Practice Address - Country:US
Practice Address - Phone:541-768-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR105826225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist