Healthcare Provider Details

I. General information

NPI: 1144695537
Provider Name (Legal Business Name): AMY SACKMASTER B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

IV. Provider business mailing address

N15454 COUNTY ROAD K LOT B16
GALESVILLE WI
54630-8744
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 608-790-4741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number127-2448
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: