MEDICARE: AMY LYNN YATES

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1477140531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LYNN YATES

Provider Business Mailing Address
First Line	:	24 WESTERN HTS
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2180
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 LOBO CANYON RD
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2172
Country	:	US
Telephone Number	:	505-287-8868
Fax Number	:

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

Provider Enumeration Date	:	12/23/2020
Last Update Date	:	12/23/2020

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