Healthcare Provider Details

I. General information

NPI: 1922519339
Provider Name (Legal Business Name): AMY LYNN ANTONICH APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 EXCHANGE ST W STE 622
SAINT PAUL MN
55102-1225
US

IV. Provider business mailing address

6452 E CARONDELET DR STE 100
TUCSON AZ
85710-2262
US

V. Phone/Fax

Practice location:
  • Phone: 651-297-9141
  • Fax:
Mailing address:
  • Phone: 715-961-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number338007
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8031-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8031-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: