Provider Demographics
NPI:1699062570
Name:PETERSON, AMY GENEE (DPT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:GENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 HOOHANA ST STE F
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-3527
Mailing Address - Country:US
Mailing Address - Phone:808-446-2032
Mailing Address - Fax:833-565-3144
Practice Address - Street 1:335 HOOHANA ST STE F
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3527
Practice Address - Country:US
Practice Address - Phone:808-446-2032
Practice Address - Fax:833-565-3144
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 3395225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI820515Medicaid