Provider Demographics
NPI:1902182496
Name:FLANNERY, AMANDA BETH KACK (CPNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH KACK
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 MIDDLE SET RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5420
Mailing Address - Country:US
Mailing Address - Phone:952-943-8200
Mailing Address - Fax:952-943-8206
Practice Address - Street 1:12200 MIDDLE SET RD STE 100
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5420
Practice Address - Country:US
Practice Address - Phone:952-943-8200
Practice Address - Fax:952-943-8206
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20111927363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics