Basic Information
| Provider Information | |||||||||
| NPI: | 1902922644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNEPP | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694906260 | ||||||||
| FaxNumber: | 2604906261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 03/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001736A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000692006 | 01 | IN | ANTHEM | OTHER | 201004450 | 05 | IN | MEDICAID |