Healthcare Provider Details

I. General information

NPI: 1225478126
Provider Name (Legal Business Name): AMY N MANDEVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 RIVERSIDE DR
WAUPACA WI
54981-1941
US

IV. Provider business mailing address

710 RIVERSIDE DR
WAUPACA WI
54981-1941
US

V. Phone/Fax

Practice location:
  • Phone: 715-256-3000
  • Fax:
Mailing address:
  • Phone: 715-256-3000
  • Fax: 715-256-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number73650
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73650
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: