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General NPI Number Information
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NPI Number | 1619114683
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Entity Type | Individual
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Provider Name | AMANDA FUSSY PTA
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Gender | Female
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Dates
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Enumeration Date | 01/13/2009
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Last Update Date | 01/13/2009
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Provider Practice Location Address
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Address Line | 915 ELM AVE E
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City | MENOMONIE
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State | WI
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Zip | 54751-1613
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Country | US
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Telephone | 715-235-9041
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Fax | 715-235-2289
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Provider Business Mailing Address
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Address Line | 915 ELM AVE E
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City | MENOMONIE
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State | WI
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Zip | 54751-1613
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Country | US
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Telephone | 715-235-9041
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Fax | 715-235-2289
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 1547-19
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License Number State | WI
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