Provider Demographics
NPI:1275620759
Name:CRUISE, AMY LEE (AT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LEE
Last Name:CRUISE
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14627 STATE HIGHTWAY B
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706
Mailing Address - Country:US
Mailing Address - Phone:417-824-2611
Mailing Address - Fax:417-269-5508
Practice Address - Street 1:3545 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-6000
Practice Address - Fax:417-269-5508
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060271662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer