Provider Demographics
NPI:1528451622
Name:CARROLL, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CARROLL
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 1:4732 BEACHSIDE RD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1323
Mailing Address - Country:US
Mailing Address - Phone:952-283-1009
Mailing Address - Fax:
Practice Address - Street 1:9325 UPLAND LN N STE 240
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4486
Practice Address - Country:US
Practice Address - Phone:763-494-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1740171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist