Healthcare Provider Details

I. General information

NPI: 1396007415
Provider Name (Legal Business Name): AMY KATHLEEN COLE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY KATHLEEN GILLUM

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 W BROADWAY AVE SUITE 300
ROBBINSDALE MN
55422-5604
US

IV. Provider business mailing address

4080 W BROADWAY AVE SUITE 300
ROBBINSDALE MN
55422-5604
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-0541
  • Fax: 763-533-1052
Mailing address:
  • Phone: 763-533-0541
  • Fax: 763-533-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: