Provider Demographics
NPI:1013566421
Name:HETZEL, AMANDA M (DC)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:M
Last Name:HETZEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:OBERC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0458
Mailing Address - Country:US
Mailing Address - Phone:920-294-3130
Mailing Address - Fax:920-294-3238
Practice Address - Street 1:505 LAKE ST
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-8820
Practice Address - Country:US
Practice Address - Phone:920-294-3130
Practice Address - Fax:920-294-3238
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5477-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor