Healthcare Provider Details

I. General information

NPI: 1003288457
Provider Name (Legal Business Name): AMY ALTAMASH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7443 JACKMAN RD
TEMPERANCE MI
48182-9223
US

IV. Provider business mailing address

7443 JACKMAN RD
TEMPERANCE MI
48182-9223
US

V. Phone/Fax

Practice location:
  • Phone: 734-850-0100
  • Fax: 734-850-0112
Mailing address:
  • Phone: 734-850-0100
  • Fax: 734-850-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704316352
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number361679
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001241905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: