Provider Demographics
NPI:1164020764
Name:MATTILA, AMY LOUISE
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LOUISE
Last Name:MATTILA
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 1:200 GARY RD
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-5402
Mailing Address - Country:US
Mailing Address - Phone:715-685-8102
Mailing Address - Fax:
Practice Address - Street 1:2500 LAKE SHORE DR E
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-2421
Practice Address - Country:US
Practice Address - Phone:715-682-3660
Practice Address - Fax:715-685-9941
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist