Healthcare Provider Details

I. General information

NPI: 1588327944
Provider Name (Legal Business Name): AMI JEY WUNDERLIN-WALDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 02/02/2025
Certification Date: 02/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 TIMBERWALK CT
LA GRANGE KY
40031-6746
US

IV. Provider business mailing address

605 S FESS AVE APT 1
BLOOMINGTON IN
47401-4972
US

V. Phone/Fax

Practice location:
  • Phone: 502-249-6829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number26935
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number267002
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.000851
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31008609A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: