Provider Demographics
NPI:1851473359
Name:HIETALA, AMY SUSANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:SUSANNE
Last Name:HIETALA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:OLMSTEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1419 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-9319
Mailing Address - Country:US
Mailing Address - Phone:920-889-0007
Mailing Address - Fax:
Practice Address - Street 1:215 N 2ND ST
Practice Address - Street 2:201
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3706
Practice Address - Country:US
Practice Address - Phone:715-425-6665
Practice Address - Fax:715-425-6677
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3470111N00000X
MNMN3382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38925900Medicaid
WIU62067Medicare UPIN
WI38925900Medicaid