Healthcare Provider Details

I. General information

NPI: 1366798902
Provider Name (Legal Business Name): AMANDA F GOPLEN APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA FAGAN

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-6400
  • Fax: 608-833-6965
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012005964
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4924-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number191157-30
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number119966
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: