Provider Demographics
NPI:1487012001
Name:HERDEGEN, AMY JEAN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:HERDEGEN
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 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-628-6623
Mailing Address - Fax:641-621-2223
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-628-6623
Practice Address - Fax:641-621-2223
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA004159OtherIOWA LICENSE