Provider Demographics
NPI:1790959815
Name:BOETTCHER, AMY ELLEN
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELLEN
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1422
Mailing Address - Country:US
Mailing Address - Phone:715-723-6520
Mailing Address - Fax:715-723-1092
Practice Address - Street 1:2525 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-1422
Practice Address - Country:US
Practice Address - Phone:715-723-6520
Practice Address - Fax:715-723-1092
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38459500Medicaid