Provider Demographics
NPI:1063013837
Name:WADSWORTH, AMY LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR # J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:212 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9114
Practice Address - Country:US
Practice Address - Phone:517-938-6085
Practice Address - Fax:517-938-6086
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704307540OtherMI LICENSE