Provider Demographics
NPI:1952676421
Name:WETZEL, AMY LYN (NP)
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:LYN
Last Name:WETZEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYN
Other - Last Name:VANDENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:280 SMITH AVE N
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-241-6600
Mailing Address - Fax:
Practice Address - Street 1:280 SMITH AVE N STE 700
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2972
Practice Address - Country:US
Practice Address - Phone:651-241-6600
Practice Address - Fax:651-241-8778
Is Sole Proprietor?:No
Enumeration Date:2012-03-17
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI144155-30163WC0200X, 163WM0705X
MNR225959-0163W00000X
WI4962-33363LA2100X
MN3845363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI462364955Medicare PIN
WI019940734Medicare PIN