Provider Demographics
NPI:1477211639
Name:WEGENER, AMY MEGAN (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MEGAN
Last Name:WEGENER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3102
Mailing Address - Country:US
Mailing Address - Phone:321-750-2221
Mailing Address - Fax:
Practice Address - Street 1:1400 ROCKLEDGE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2846
Practice Address - Country:US
Practice Address - Phone:321-735-8960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner