Provider Demographics
NPI:1124451414
Name:FARRELL, AMANDA ANN (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:FARRELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:A
Other - Last Name:JOYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-4990
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-4990
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7219-33363L00000X
WI194211-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse