Provider Demographics
NPI:1154073997
Name:NORDSTROM, AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11390 W THEODORE TRECKER WAY
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1135
Mailing Address - Country:US
Mailing Address - Phone:414-928-1401
Mailing Address - Fax:
Practice Address - Street 1:11390 W THEODORE TRECKER WAY
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-1135
Practice Address - Country:US
Practice Address - Phone:414-928-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI259959163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse