Provider Demographics
NPI:1104869767
Name:WRENTMORE, AMY L (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:WRENTMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LEE ST FL 4
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-924-5321
Practice Address - Fax:434-982-3816
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12445208000000X
VA0101241326208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204717Medicaid
VA1104869767Medicaid
NH30204717Medicaid
VAVV1674AMedicare PIN
NHRE7884Medicare PIN