Healthcare Provider Details

I. General information

NPI: 1245768894
Provider Name (Legal Business Name): AMANDA MARIE VITOVSKY APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MAIN ST
ASHLAND WI
54806-3696
US

IV. Provider business mailing address

15735 W US HIGHWAY 63
HAYWARD WI
54843-6475
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-2200
  • Fax: 715-685-1185
Mailing address:
  • Phone: 715-934-0710
  • Fax: 715-598-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7697.33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166713
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: