Healthcare Provider Details

I. General information

NPI: 1417818030
Provider Name (Legal Business Name): AMI MANTYCH APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date: 11/21/2025
Reactivation Date: 08/21/2026

III. Provider practice location address

707 S UNIVERSITY AVE
BEAVER DAM WI
53916-3027
US

IV. Provider business mailing address

W9675 COUSINS CT
BEAVER DAM WI
53916-9242
US

V. Phone/Fax

Practice location:
  • Phone: 920-382-4483
  • Fax:
Mailing address:
  • Phone: 920-382-4483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18755-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number164101
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: