Provider Demographics
NPI:1790111219
Name:MACON, AMY (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 REDBUD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8461
Mailing Address - Country:US
Mailing Address - Phone:601-594-1032
Mailing Address - Fax:
Practice Address - Street 1:201 E LAYFAIR DR
Practice Address - Street 2:SUITE 125
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7604
Practice Address - Country:US
Practice Address - Phone:601-420-6867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist