Basic Information
| Provider Information | |||||||||
| NPI: | 1952676421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WETZEL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDENBERG | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 280 SMITH AVE N | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512416600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 280 SMITH AVE N STE 700 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512416600 | ||||||||
| FaxNumber: | 6512418778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2012 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 144155-30 | WI | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 163W00000X | R225959-0 | MN | N | Nursing Service Providers | Registered Nurse | 163WM0705X | 144155-30 | WI | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363LA2100X | 4962-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 3845 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.