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
StateLicense IDTaxonomies
KY003235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000578073OtherBLUE CROSS BLUE SHIELD
KY000000578073OtherBLUE CROSS BLUE SHIELD
KY5018308Medicare ID - Type Unspecified