Provider Demographics
NPI:1922548809
Name:PORTER, AMY JO (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:PORTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:HAUGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6614 LACASSE DR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7703
Mailing Address - Country:US
Mailing Address - Phone:651-235-2070
Mailing Address - Fax:
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1039174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist