Provider Demographics
NPI:1659500965
Name:PRINCE, AMBER (PTA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PRINCE
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 1:10100 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8234
Mailing Address - Country:US
Mailing Address - Phone:815-713-2738
Mailing Address - Fax:815-713-2797
Practice Address - Street 1:2334 SE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-7256
Practice Address - Country:US
Practice Address - Phone:918-331-9184
Practice Address - Fax:918-331-9187
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1269225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200117320AMedicaid
OK900522529Medicare PIN