Provider Demographics
NPI:1548205412
Name:PERSON, AMY L (DC)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:L
Last Name:PERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 BUCKLAND RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3737
Mailing Address - Country:US
Mailing Address - Phone:860-648-2259
Mailing Address - Fax:860-648-2866
Practice Address - Street 1:469 BUCKLAND RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-648-2259
Practice Address - Fax:860-648-2866
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04443Medicare UPIN
350001392Medicare ID - Type Unspecified