Provider Demographics
NPI:1649770140
Name:ELLIS, AMIE JO (PTA)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:JO
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6140
Mailing Address - Country:US
Mailing Address - Phone:740-801-1204
Mailing Address - Fax:
Practice Address - Street 1:433 OBETZ RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4098
Practice Address - Country:US
Practice Address - Phone:740-801-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011100225200000X
WY0950225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant