Provider Demographics
NPI:1497407837
Name:FEDIE, AMY ROSE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:FEDIE
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 1:5220 PAINTER CREEK GRN
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MN
Mailing Address - Zip Code:55359-5400
Mailing Address - Country:US
Mailing Address - Phone:612-386-0763
Mailing Address - Fax:
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-318-8706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77739367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered