Provider Demographics
NPI:1518513779
Name:FOSSA, AMY MARTIN (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARTIN
Last Name:FOSSA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8991 UNIVERSITY PKWY APT 238
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-9400
Mailing Address - Country:US
Mailing Address - Phone:850-407-4330
Mailing Address - Fax:850-308-5161
Practice Address - Street 1:8991 UNIVERSITY PKWY
Practice Address - Street 2:UNIT 238
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-9400
Practice Address - Country:US
Practice Address - Phone:850-407-4330
Practice Address - Fax:850-308-5161
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10504225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT10504OtherLICENSE