Healthcare Provider Details

I. General information

NPI: 1710947585
Provider Name (Legal Business Name): AMANDA CORINNE KOPP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5590 POLWORTH ST
FITCHBURG WI
53711-5484
US

IV. Provider business mailing address

535 ECHO VALLEY RD
BROOKLYN WI
53521-9448
US

V. Phone/Fax

Practice location:
  • Phone: 847-602-9140
  • Fax:
Mailing address:
  • Phone: 608-215-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number148876-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: