Healthcare Provider Details

I. General information

NPI: 1619974508
Provider Name (Legal Business Name): AMY GABRIELLE GRIZZARD PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050B VILLAGE SQUARE DR
PADUCAH KY
42001-9499
US

IV. Provider business mailing address

74 MOHAWK LN
BENTON KY
42025-6948
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-0681
  • Fax: 270-442-9748
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003235
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: