Provider Demographics
NPI:1205944972
Name:BODENSTEINER, AMY JO ANGEL (PAC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO ANGEL
Last Name:BODENSTEINER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:ANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 NINTH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677
Mailing Address - Country:US
Mailing Address - Phone:641-435-4133
Mailing Address - Fax:641-435-4003
Practice Address - Street 1:80 AMHEARST BOULEVARD
Practice Address - Street 2:SUITE 400
Practice Address - City:NASHUA
Practice Address - State:IA
Practice Address - Zip Code:50658-9712
Practice Address - Country:US
Practice Address - Phone:641-435-4133
Practice Address - Fax:641-435-4003
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant