Basic Information
| Provider Information | |||||||||
| NPI: | 1629043492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | L.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 13TH ST SW | ||||||||
| Address2: | |||||||||
| City: | OWATONNA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550603802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074461033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1961 CARDINAL LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550214353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073332986 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5634 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 058287500 | 05 | MN | MEDICAID |