Basic Information
| Provider Information | |||||||||
| NPI: | 1124451414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOYCE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452248 | ||||||||
| Practice Location | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7219-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 194211-30 | WI | N | Nursing Service Providers | Registered Nurse |
No ID Information.