Provider Demographics
NPI:1336192707
Name:SHEFCHIK, AMANDA L (NP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:L
Last Name:SHEFCHIK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LEA
Other - Last Name:PEOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-3640
Mailing Address - Fax:920-433-3716
Practice Address - Street 1:744 S WEBSTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-433-3716
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134756-030163W00000X
WI2563-033363L00000X
WI134756-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41259200Medicaid
WI41259200Medicaid
WI0000031Medicare Oscar/Certification
WI000028Medicare Oscar/Certification
WIQ36144Medicare UPIN