Provider Demographics
NPI:1376880799
Name:RASMUSSEN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RASMUSSEN
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:N2289 HUNTINGTON CT
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3102
Mailing Address - Country:US
Mailing Address - Phone:608-498-2275
Mailing Address - Fax:
Practice Address - Street 1:2511 GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5900
Practice Address - Country:US
Practice Address - Phone:608-775-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14262-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist