Basic Information
| Provider Information | |||||||||
| NPI: | 1619386430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEITZIG | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 W BRIDGEPORT ST | ||||||||
| Address2: | |||||||||
| City: | WHITE HALL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620921001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173742144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 W BRIDGEPORT ST | ||||||||
| Address2: | |||||||||
| City: | WHITE HALL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620921001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173742144 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/02/2018 | ||||||||
| NPIReactivationDate: | 09/19/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2014037473 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 160.001512 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.