Provider Demographics
NPI:1336145499
Name:WALENGA, AMY (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WALENGA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3146
Mailing Address - Country:US
Mailing Address - Phone:508-771-9599
Mailing Address - Fax:508-771-1986
Practice Address - Street 1:94 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3146
Practice Address - Country:US
Practice Address - Phone:508-771-9599
Practice Address - Fax:508-771-1986
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500001167Medicare ID - Type Unspecified
Q03454Medicare UPIN