Provider Demographics
NPI:1922279751
Name:GULZOW, AMY JACQUELINE (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JACQUELINE
Last Name:GULZOW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:JOSEPH
Mailing Address - State:OR
Mailing Address - Zip Code:97846-0703
Mailing Address - Country:US
Mailing Address - Phone:541-398-0007
Mailing Address - Fax:541-960-3904
Practice Address - Street 1:709 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JOSEPH
Practice Address - State:OR
Practice Address - Zip Code:97846-8513
Practice Address - Country:US
Practice Address - Phone:541-398-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2023-02-01
Deactivation Date:2022-10-18
Deactivation Code:
Reactivation Date:2023-02-01
Provider Licenses
StateLicense IDTaxonomies
OR12700247200000X
OR106415374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other