MEDICARE: AMY LOUISE WILLETT

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
1	225700000X	Massage Therapist	108882	KY

General Provider Information

NPI Number	:	1346884699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LOUISE WILLETT

Provider Business Mailing Address
First Line	:	8215 SHELBYVILLE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-5421
Country	:	US
Telephone Number	:	502-634-1867
Fax Number	:

Provider Business Practice Location Address
First Line	:	8215 SHELBYVILLE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-5421
Country	:	US
Telephone Number	:	502-634-1867
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2019
Last Update Date	:	10/30/2019

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