Provider Demographics
NPI:1528042041
Name:GUNDERSON, AMY ELIZABETH (LICENSED ATHLETIC TR)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:LICENSED ATHLETIC TR
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:KNUTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 8075
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-8075
Mailing Address - Country:US
Mailing Address - Phone:715-421-5257
Mailing Address - Fax:715-421-0111
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-421-5257
Practice Address - Fax:715-421-0111
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1180392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer