Provider Demographics
NPI:1912199480
Name:BLAETTNER, AMY LYNN (OTR)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:BLAETTNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 THORNBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3874
Mailing Address - Country:US
Mailing Address - Phone:260-515-9071
Mailing Address - Fax:
Practice Address - Street 1:5736 THORNBRIAR LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3874
Practice Address - Country:US
Practice Address - Phone:260-515-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000439A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist