Provider Demographics
NPI:1356486849
Name:VANNEDERPELT, AMY JOHANNA (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:JOHANNA
Last Name:VANNEDERPELT
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-4551
Mailing Address - Country:US
Mailing Address - Phone:781-492-7669
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2827
Practice Address - Country:US
Practice Address - Phone:978-934-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer