Provider Demographics
NPI:1215703137
Name:LOOSE, AMY S (RN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:LOOSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:KIESNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:N9139 N COOP RD APT G
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-9517
Mailing Address - Country:US
Mailing Address - Phone:920-418-2390
Mailing Address - Fax:
Practice Address - Street 1:505 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI191438-30163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult