Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 5501017764 | MI |
NPI | 1124373444 |
---|---|
Provider Name | Amy Fanning Humphrey |
First Address | Brighton, MI 48116-3703 |
Second Address | Brighton, MI 46116 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2012 |
Last Update Date | 22/10/2018 |