Provider Demographics
NPI:1437814878
Name:WIEBUSCH, AMY ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ANN
Last Name:WIEBUSCH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2499
Mailing Address - Country:US
Mailing Address - Phone:800-748-3243
Mailing Address - Fax:
Practice Address - Street 1:43 W PRAIRIE SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9854
Practice Address - Country:US
Practice Address - Phone:208-772-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58166163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID58166OtherRN