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NPI Code Detail

MEDICARE: MRS. AMY LYNN KOUDELKA

MEDICARE: MRS. AMY LYNN KOUDELKA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist070010691IL

General Provider Information

NPI Number : 1215101191
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. AMY LYNN KOUDELKA
Provider Business Mailing Address
First Line : 818 E BROADWAY ST
Second Line : PO BOX 297
City : SPARTA
State : IL
Zip : 62286-1820
Country : US
Telephone Number : 618-443-2177
Fax Number : 618-443-1383
Provider Business Practice Location Address
First Line : 1300 N MARKET ST
Second Line :
City : SPARTA
State : IL
Zip : 62286-1048
Country : US
Telephone Number : 618-443-2177
Fax Number : 618-443-4731
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/22/2008
Last Update Date : 07/05/2012

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