Provider Demographics
NPI:1477178259
Name:LALLENSACK, AMANDA C (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:LALLENSACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-0396
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:
Practice Address - Street 1:8201 MISH KO SWEN DR
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8631
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist