Provider Demographics
NPI:1699007633
Name:BANDT, AMY (CNM)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BANDT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17791 IKARIA CT
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1925 WOODWINDS DR
Practice Address - Street 2:SUITE 250
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4445
Practice Address - Country:US
Practice Address - Phone:651-232-0100
Practice Address - Fax:651-232-6888
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11220-NM367A00000X
MNR206694-5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNM76521Medicare PIN