Provider Demographics
NPI:1588424873
Name:RED OWL, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RED OWL
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 1:2920 SHERIDAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8191
Mailing Address - Country:US
Mailing Address - Phone:605-716-1837
Mailing Address - Fax:605-348-0479
Practice Address - Street 1:3505 CAMBELL ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0141
Practice Address - Country:US
Practice Address - Phone:605-716-1837
Practice Address - Fax:605-348-0479
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCHW509172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker