Basic Information
Provider Information | |||||||||
NPI: | 1508845728 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEDLEY | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3355 GLENDALE AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436142426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193835322 | ||||||||
FaxNumber: | 4193836235 | ||||||||
Practice Location | |||||||||
Address1: | 3125 TRANSVERSE DR | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436148008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193833780 | ||||||||
FaxNumber: | 4193832023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2006 | ||||||||
LastUpdateDate: | 10/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.005039RX | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 1223P0221X | 2901016874 | MI | Y |   | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
ID | Type | State | Issuer | Description | 3244055 | 05 | MI |   | MEDICAID | J801645 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |