Provider Demographics
NPI:1417286063
Name:CHRISTNOVICH, AMY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:CHRISTNOVICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:LAZALIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2700 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7247
Mailing Address - Country:US
Mailing Address - Phone:920-223-0598
Mailing Address - Fax:
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7247
Practice Address - Country:US
Practice Address - Phone:920-223-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11371-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417286063Medicaid