Provider Demographics
NPI:1114597168
Name:CARLSON-DONDERO, AMANDA JO (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:CARLSON-DONDERO
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, FNP-BC
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:4448 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4800
Practice Address - Country:US
Practice Address - Phone:414-281-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2019053373363LF0000X
WI11274-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100182065Medicaid