Provider Demographics
NPI:1073364592
Name:ABEGGLEN, AMANDA ROSE (APNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:ABEGGLEN
Suffix:
Gender:F
Credentials:APNP, PMHNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:643 E ALLOUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2005
Mailing Address - Country:US
Mailing Address - Phone:414-552-8248
Mailing Address - Fax:
Practice Address - Street 1:301 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2241
Practice Address - Country:US
Practice Address - Phone:920-431-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15206-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health