MEDICARE: AMY LYNN PROTHEROE OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	20805	FL

General Provider Information

NPI Number	:	1669097135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LYNN PROTHEROE OTR

Provider Business Mailing Address
First Line	:	10265 GANDY BLVD N APT 1003
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-2332
Country	:	US
Telephone Number	:	407-733-1165
Fax Number	:

Provider Business Practice Location Address
First Line	:	2725 ROBIE AVE
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-9619
Country	:	US
Telephone Number	:	800-626-3876
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	07/24/2020

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