Provider Demographics
NPI:1164735536
Name:ANDERSON, AMY L (LPN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-2906
Mailing Address - Country:US
Mailing Address - Phone:715-732-4643
Mailing Address - Fax:
Practice Address - Street 1:614 BAXTER ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-2906
Practice Address - Country:US
Practice Address - Phone:715-732-4643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27115-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse