=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548272081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY LOUISE ELLIS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 S CLYDE MORRIS BLVD SUITE 200
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-8976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-304-8112
-----------------------------------------------------
Fax | 386-304-8014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 S CLYDE MORRIS BLVD SUITE 200
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-8976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-304-8112
-----------------------------------------------------
Fax | 386-304-8014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT3183
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------