Provider Demographics
NPI:1629043492
Name:SIMMONS, AMY (LPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 13TH ST SW
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3802
Mailing Address - Country:US
Mailing Address - Phone:507-446-1033
Mailing Address - Fax:
Practice Address - Street 1:1961 CARDINAL LN
Practice Address - Street 2:SUITE A
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4353
Practice Address - Country:US
Practice Address - Phone:507-333-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN058287500Medicaid
MN650000883Medicare ID - Type Unspecified