Provider Demographics
NPI:1093896540
Name:WYBENGA, AMY MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:WYBENGA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:645 MCQUEEN SMITH RD N STE 309
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7269
Practice Address - Country:US
Practice Address - Phone:334-358-2010
Practice Address - Fax:334-358-2013
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-061747163WG0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51533030OtherBLUE CROSS