1851473359 NPI number — DR. AMY SUSANNE HIETALA DC

Table of content: DR. AMY SUSANNE HIETALA DC (NPI 1851473359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851473359 NPI number — DR. AMY SUSANNE HIETALA DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIETALA
Provider First Name:
AMY
Provider Middle Name:
SUSANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OLMSTEAD
Provider Other First Name:
AMY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1851473359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1419 FRANKLIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54002-9319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-889-0007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N 2ND ST
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54022-3706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-425-6665
Provider Business Practice Location Address Fax Number:
715-425-6677
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3470 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: MN3382 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38925900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com