Provider Demographics
NPI:1528335189
Name:NOLAN, AMY LYNN (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:NOLAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 GRIMES AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3217
Mailing Address - Country:US
Mailing Address - Phone:763-450-2737
Mailing Address - Fax:763-588-8252
Practice Address - Street 1:3130 GRIMES AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-3217
Practice Address - Country:US
Practice Address - Phone:763-450-2737
Practice Address - Fax:763-588-8252
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1510225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant