Healthcare Provider Details

I. General information

NPI: 1568414027
Provider Name (Legal Business Name): AMANDA LYNNE HUYCK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA LYNNE MIETTINEN CRNA, MSNA

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 SOUTH STATE STREET 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-4000
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024166853
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704269636
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: