Provider Demographics
NPI:1598362337
Name:HUGHSON, AMY LOUISE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:HUGHSON
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:PO BOX 8473
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92341-8473
Mailing Address - Country:US
Mailing Address - Phone:909-324-1134
Mailing Address - Fax:
Practice Address - Street 1:33668 ANGELES DRIVE
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY LAKE
Practice Address - State:CA
Practice Address - Zip Code:92341-9234
Practice Address - Country:US
Practice Address - Phone:951-201-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85050225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty