Healthcare Provider Details

I. General information

NPI: 1487805495
Provider Name (Legal Business Name): AMY E TRUCKEY PAC, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 HOLMGREN WAY
GREEN BAY WI
54304-5224
US

IV. Provider business mailing address

2411 HOLMGREN WAY
GREEN BAY WI
54304-5224
US

V. Phone/Fax

Practice location:
  • Phone: 920-888-2828
  • Fax: 920-338-6869
Mailing address:
  • Phone: 920-888-2828
  • Fax: 920-338-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number288823
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2888-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: