Provider Demographics
NPI:1740263128
Name:AMUNDSEN, IRENE MARILYN (RN BSN)
Entity type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARILYN
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:MRS
Other - First Name:IRENE
Other - Middle Name:MARILYN
Other - Last Name:PISCHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:W7201 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:BURNETT
Mailing Address - State:WI
Mailing Address - Zip Code:53922-9779
Mailing Address - Country:US
Mailing Address - Phone:920-324-3801
Mailing Address - Fax:
Practice Address - Street 1:W7201 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:BURNETT
Practice Address - State:WI
Practice Address - Zip Code:53922-9779
Practice Address - Country:US
Practice Address - Phone:920-324-3801
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52614030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38273500Medicaid