Provider Demographics
NPI:1508131178
Name:STROUP, AMY R (LPN, LMT, FACIALIST)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:R
Last Name:STROUP
Suffix:
Gender:F
Credentials:LPN, LMT, FACIALIST
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:R
Other - Last Name:MARRIAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN, LMT, FACIALIST
Mailing Address - Street 1:9124 NW 35TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6400
Mailing Address - Country:US
Mailing Address - Phone:954-895-2697
Mailing Address - Fax:
Practice Address - Street 1:5460 N STATE ROAD 7 STE 217
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33319-2969
Practice Address - Country:US
Practice Address - Phone:954-895-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN0547061164W00000X
FLMA29603247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No164W00000XNursing Service ProvidersLicensed Practical Nurse