Provider Demographics
NPI:1346675261
Name:GENDRON, AMY ROSE (LAC)
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:ROSE
Last Name:GENDRON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N MILL ST
Mailing Address - Street 2:UNIT #114
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1559
Mailing Address - Country:US
Mailing Address - Phone:970-236-6476
Mailing Address - Fax:
Practice Address - Street 1:225 N MILL ST
Practice Address - Street 2:UNIT 114
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1559
Practice Address - Country:US
Practice Address - Phone:970-236-6476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002179171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist