Provider Demographics
NPI:1548379498
Name:DIERCKS, AMANDA RAE (DC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LANGLADE RD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2738
Mailing Address - Country:US
Mailing Address - Phone:715-623-3761
Mailing Address - Fax:715-623-3764
Practice Address - Street 1:1111 LANGLADE RD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2738
Practice Address - Country:US
Practice Address - Phone:715-623-3761
Practice Address - Fax:715-623-3764
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4179-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor