Healthcare Provider Details

I. General information

NPI: 1104869767
Provider Name (Legal Business Name): AMY L. WRENTMORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LEE ST FL 4
CHARLOTTESVILLE VA
22908-0001
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-5321
  • Fax: 434-982-3816
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12445
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101241326
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: