Provider Demographics
NPI:1518528710
Name:FETTEROLF, AMANDA (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FETTEROLF
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1680 BEACHWAY
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-9343
Mailing Address - Country:US
Mailing Address - Phone:989-387-2487
Mailing Address - Fax:
Practice Address - Street 1:815 N CLARE AVE STE B
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-8177
Practice Address - Country:US
Practice Address - Phone:989-539-6731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704226162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily