Provider Demographics
NPI:1245571363
Name:DAMERON, AMY MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:DAMERON
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 1:1701 S CREASY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4972
Mailing Address - Country:US
Mailing Address - Phone:765-423-6336
Mailing Address - Fax:
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-423-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011701A225100000X
FLPT27464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009932500Medicaid