Provider Demographics
NPI:1114194172
Name:WACKER, AMANDA JEANNE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:JEANNE
Last Name:WACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 EAGLE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1284
Mailing Address - Country:US
Mailing Address - Phone:952-465-6853
Mailing Address - Fax:
Practice Address - Street 1:8690 EAGLE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1284
Practice Address - Country:US
Practice Address - Phone:952-465-6853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist