Provider Demographics
NPI:1659312254
Name:AMEND, MARY ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:AMEND
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 W DALE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1901
Mailing Address - Country:US
Mailing Address - Phone:319-226-9888
Mailing Address - Fax:319-226-9889
Practice Address - Street 1:146 W DALE ST STE 201
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-226-9888
Practice Address - Fax:319-226-9889
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1659312254Medicaid
Q52905Medicare UPIN