Provider Demographics
NPI:1922519339
Name:ANTONICH, AMY LYNN (APNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:ANTONICH
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 EXCHANGE ST W
Mailing Address - Street 2:STE 622
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1225
Mailing Address - Country:US
Mailing Address - Phone:651-297-9141
Mailing Address - Fax:
Practice Address - Street 1:17 EXCHANGE ST W
Practice Address - Street 2:STE 622
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1225
Practice Address - Country:US
Practice Address - Phone:651-297-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8031-33207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine