Provider Demographics
NPI:1154081354
Name:FLETCHER, AMY (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:IL
Mailing Address - Zip Code:61738-1212
Mailing Address - Country:US
Mailing Address - Phone:309-825-4552
Mailing Address - Fax:
Practice Address - Street 1:1501 MERCY CREEK DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9597
Practice Address - Country:US
Practice Address - Phone:309-268-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009272225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant