Provider Demographics
NPI:1871930933
Name:FICKLIN, AMY LYNN (ATC, AT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:FICKLIN
Suffix:
Gender:F
Credentials:ATC, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3158
Mailing Address - Country:US
Mailing Address - Phone:937-681-9497
Mailing Address - Fax:
Practice Address - Street 1:2151 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3158
Practice Address - Country:US
Practice Address - Phone:937-681-9497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0031722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer