Provider Demographics
NPI:1104109768
Name:KING, AMANDA L (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:NP
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC CRITICAL CARE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-3360
Mailing Address - Fax:414-266-3563
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC CRITICAL CARE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3360
Practice Address - Fax:414-266-3563
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI165109363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104109768Medicaid
WI1104109768Medicaid
WI736012368Medicare PIN