Healthcare Provider Details

I. General information

NPI: 1053033076
Provider Name (Legal Business Name): AMY LYNN FUST SHAVER BS, OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY LYNN FUST BS

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

1675 W COVENANT HILL CT
EAGLE ID
83616-7098
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax:
Mailing address:
  • Phone: 925-683-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: