Healthcare Provider Details

I. General information

NPI: 1154095404
Provider Name (Legal Business Name): AMBER LYNN WANDRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 185TH ST W STE 100
LAKEVILLE MN
55044-6696
US

IV. Provider business mailing address

10450 185TH ST W STE 100
LAKEVILLE MN
55044-6696
US

V. Phone/Fax

Practice location:
  • Phone: 612-509-6690
  • Fax: 612-509-6699
Mailing address:
  • Phone: 612-509-6690
  • Fax: 612-509-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1154095404
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: