Provider Demographics
NPI:1487260774
Name:TRUOG, AMY C (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:TRUOG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:C
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:612 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4114
Mailing Address - Country:US
Mailing Address - Phone:217-306-4864
Mailing Address - Fax:
Practice Address - Street 1:W227N16857 TILLIE LAKE CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-9000
Practice Address - Country:US
Practice Address - Phone:262-365-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist