Provider Demographics
NPI:1225478126
Name:MANDEVILLE, AMY NICOLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:MANDEVILLE
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 1:710 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1941
Mailing Address - Country:US
Mailing Address - Phone:715-256-3000
Mailing Address - Fax:715-256-3039
Practice Address - Street 1:710 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1941
Practice Address - Country:US
Practice Address - Phone:715-256-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1324207Q00000X
ORMD178973207Q00000X
WI73650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine