Basic Information
| Provider Information | |||||||||
| NPI: | 1710178603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.A.ED., IECE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 WALLER AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592719448 | ||||||||
| FaxNumber: | 8592726893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 222Q00000X | 201133920 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30615058 | 05 | KY | MEDICAID |