Provider Demographics
NPI:1487252383
Name:OOTHOUDT, AMY LARAYNE (STS PROVIDER)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LARAYNE
Last Name:OOTHOUDT
Suffix:
Gender:F
Credentials:STS PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13392 THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-6110
Mailing Address - Country:US
Mailing Address - Phone:320-630-7821
Mailing Address - Fax:
Practice Address - Street 1:13392 THOMAS DR
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-6110
Practice Address - Country:US
Practice Address - Phone:320-630-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN383814343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN383814OtherSTS NUMBER