Provider Demographics
NPI:1609237502
Name:GOTTSCHALK, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOTTSCHALK
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 1:1222 AMELIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2707
Mailing Address - Country:US
Mailing Address - Phone:248-342-8446
Mailing Address - Fax:
Practice Address - Street 1:11368 ALLEN RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4372
Practice Address - Country:US
Practice Address - Phone:734-403-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily