Provider Demographics
NPI:1750309514
Name:ETTERS, AMIE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMIE
Middle Name:LYNN
Last Name:ETTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S TEBO ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:MO
Mailing Address - Zip Code:65360-1161
Mailing Address - Country:US
Mailing Address - Phone:660-647-2147
Mailing Address - Fax:660-647-2160
Practice Address - Street 1:100 S TEBO ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:MO
Practice Address - Zip Code:65360-1161
Practice Address - Country:US
Practice Address - Phone:660-647-2147
Practice Address - Fax:660-647-2160
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10871482OtherCAQH
MO24313042OtherBLUE CROSS BLUE SHIELD KC
MO2583144OtherAETNA
MOG87054Medicare UPIN
MOT147900Medicare ID - Type UnspecifiedMEDICARE