Healthcare Provider Details

I. General information

NPI: 1902967359
Provider Name (Legal Business Name): AMY LYNNE HEFFERNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E MAIN ST STE 300
WAUKESHA WI
53186-3984
US

IV. Provider business mailing address

1800 E MAIN ST STE 300
WAUKESHA WI
53186-3984
US

V. Phone/Fax

Practice location:
  • Phone: 262-549-4555
  • Fax: 262-549-9750
Mailing address:
  • Phone: 262-549-4555
  • Fax: 262-549-9750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3874
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: