Provider Demographics
NPI:1457571986
Name:KOUTSOPOULOS, AMY LYNN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:KOUTSOPOULOS
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 1:219 PARK MEADOW LN APT I
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-7354
Mailing Address - Country:US
Mailing Address - Phone:440-506-5255
Mailing Address - Fax:
Practice Address - Street 1:361 E 45TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-5505
Practice Address - Country:US
Practice Address - Phone:440-233-8180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121015164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse