Provider Demographics
NPI:1013529858
Name:SQUIRES, AMBER NICOLE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:NICOLE
Other - Last Name:KYUROV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2044 MIDLAND AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2044 MIDLAND AVE APT 2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2287
Practice Address - Country:US
Practice Address - Phone:502-609-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265140225700000X
MO2020027163225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist