Provider Demographics
NPI:1346335254
Name:KENWORTHY, AMY T (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:T
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 DEER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-9780
Mailing Address - Country:US
Mailing Address - Phone:307-335-8248
Mailing Address - Fax:
Practice Address - Street 1:800 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1943
Practice Address - Country:US
Practice Address - Phone:715-258-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6969A207P00000X
MEMD22847207R00000X
OH35.053893207R00000X
IL36143235207R00000X
WI285-320207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119346500Medicaid
WY10139Medicare ID - Type Unspecified
WY119346500Medicaid