Provider Demographics
NPI:1952735300
Name:PEMBERTON, AMY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4914 N BELT ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-5669
Mailing Address - Country:US
Mailing Address - Phone:509-869-9388
Mailing Address - Fax:
Practice Address - Street 1:4914 N BELT ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-5669
Practice Address - Country:US
Practice Address - Phone:509-869-9388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60376235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952735300Medicare PIN