Provider Demographics
NPI:1356684880
Name:SUINO-MALCOLM, AMANDA LEE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:SUINO-MALCOLM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:SHOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13447 W COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2259
Mailing Address - Country:US
Mailing Address - Phone:715-558-7883
Mailing Address - Fax:715-558-7348
Practice Address - Street 1:13447 W COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2259
Practice Address - Country:US
Practice Address - Phone:715-558-7883
Practice Address - Fax:715-558-7348
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI141483-30363LF0000X
WI5436-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356684880Medicaid