Healthcare Provider Details

I. General information

NPI: 1144633165
Provider Name (Legal Business Name): AMY HUTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

IV. Provider business mailing address

390 PAQUIN DR
SOMERSET WI
54025-7586
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax:
Mailing address:
  • Phone: 651-210-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: