Provider Demographics
NPI:1942577358
Name:FILLMORE, AMY J (LPN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13069 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-9465
Mailing Address - Country:US
Mailing Address - Phone:937-780-6302
Mailing Address - Fax:
Practice Address - Street 1:13069 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:OH
Practice Address - Zip Code:45135-9465
Practice Address - Country:US
Practice Address - Phone:937-780-6302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.112645164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse