Basic Information
| Provider Information | |||||||||
| NPI: | 1669771051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4415 W 36 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | 9529277687 | ||||||||
| Practice Location | |||||||||
| Address1: | 4415 W 36 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | 9529277687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 03/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 8703 | MN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.