Provider Demographics
NPI: | 1619974508 |
---|---|
Name: | GRIZZARD, AMY GABRIELLE (PHYSICAL THERAPIST) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | AMY |
Middle Name: | GABRIELLE |
Last Name: | GRIZZARD |
Suffix: | |
Gender: | F |
Credentials: | PHYSICAL THERAPIST |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 74 MOHAWK LN |
Mailing Address - Street 2: | |
Mailing Address - City: | BENTON |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 42025-6948 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5050B VILLAGE SQUARE DR |
Practice Address - Street 2: | |
Practice Address - City: | PADUCAH |
Practice Address - State: | KY |
Practice Address - Zip Code: | 42001-9499 |
Practice Address - Country: | US |
Practice Address - Phone: | 270-443-0681 |
Practice Address - Fax: | 270-442-9748 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-07 |
Last Update Date: | 2010-03-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 003235 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 000000578073 | Other | BLUE CROSS BLUE SHIELD |
KY | 000000578073 | Other | BLUE CROSS BLUE SHIELD |
KY | 5018308 | Medicare ID - Type Unspecified |