Provider Demographics
NPI:1770901712
Name:WANTLAND, AMELIA ROSE NORDMANN (MD)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:ROSE NORDMANN
Last Name:WANTLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMELIA
Other - Middle Name:ROSE
Other - Last Name:NORDMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:866-273-5392
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1603 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1087
Practice Address - Country:US
Practice Address - Phone:502-451-5955
Practice Address - Fax:502-451-5925
Is Sole Proprietor?:No
Enumeration Date:2014-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49821207Q00000X
KYR3679390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100361700Medicaid