Provider Demographics
NPI:1427246016
Name:MOORE, AMY ELIZABETH
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 COPILOT WAY
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7004
Mailing Address - Country:US
Mailing Address - Phone:920-265-9462
Mailing Address - Fax:
Practice Address - Street 1:5121 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1308
Practice Address - Country:US
Practice Address - Phone:480-296-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10725-024225100000X
AZ7673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist