Provider Demographics
NPI:1689336851
Name:MOEGGENBERG, AMANDA LOUISE (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LOUISE
Last Name:MOEGGENBERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:LOUISE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1049 E NEWELL ST
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8795
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:231-787-1304
Practice Address - Street 1:1049 E NEWELL ST
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8795
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:231-787-1304
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249865163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse