Provider Demographics
NPI:1275000853
Name:STJOHN, AMY (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:STJOHN
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 1/2 EAST ST
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-1813
Mailing Address - Country:US
Mailing Address - Phone:518-232-7420
Mailing Address - Fax:
Practice Address - Street 1:101 1/2 EAST ST
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1813
Practice Address - Country:US
Practice Address - Phone:518-232-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008825156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty