Provider Demographics
NPI:1275025520
Name:BRAATZ, AMANDA LYNN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:BRAATZ
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 1:428 MINNESOTA ST STE 500
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2666
Mailing Address - Country:US
Mailing Address - Phone:651-661-4986
Mailing Address - Fax:
Practice Address - Street 1:428 MINNESOTA ST STE 500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2666
Practice Address - Country:US
Practice Address - Phone:651-661-4986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-02
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6553363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1275025520Medicaid