Healthcare Provider Details

I. General information

NPI: 1770727620
Provider Name (Legal Business Name): AMY BETH WYENBERG LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E 16TH ST SUITE W
VANCOUVER WA
98663-3411
US

IV. Provider business mailing address

PO BOX 822467
VANCOUVER WA
98682-0054
US

V. Phone/Fax

Practice location:
  • Phone: 360-931-0376
  • Fax:
Mailing address:
  • Phone: 360-931-0376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMA00020236
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: