Healthcare Provider Details

I. General information

NPI: 1386952661
Provider Name (Legal Business Name): AMANDA MARIE HEGEMAN BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2047 N COMMERCE ST
MILWAUKEE WI
53212-3484
US

IV. Provider business mailing address

2047 N COMMERCE ST
MILWAUKEE WI
53212-3484
US

V. Phone/Fax

Practice location:
  • Phone: 414-699-7553
  • Fax:
Mailing address:
  • Phone: 414-699-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number158907030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: