Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 5501012840 | MI |
Y | 2251P0200X | Physical Therapist - Pediatrics | 5501012840 | MI |
NPI | 1063728509 |
---|---|
Provider Name | Amy Wallenburg |
First Address | Zeeland, MI 49464-1281 |
Second Address | Zeeland, MI 49464-1281 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2010 |
Last Update Date | 05/09/2010 |