Provider Demographics
NPI:1275270548
Name:DALY, AMBER ROSE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ROSE
Last Name:DALY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-2957
Mailing Address - Country:US
Mailing Address - Phone:618-997-1365
Mailing Address - Fax:
Practice Address - Street 1:1301 E DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-3846
Practice Address - Country:US
Practice Address - Phone:618-997-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPENDING225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant