Provider Demographics
NPI:1306684956
Name:DENELL, AMBER NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:AMBER
Middle Name:NICOLE
Last Name:DENELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:NICOLE
Other - Last Name:LOVATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2647 WITZEL AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8194
Mailing Address - Country:US
Mailing Address - Phone:906-284-3322
Mailing Address - Fax:
Practice Address - Street 1:N6663 ROLLING MEADOWS DR STE I
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9501
Practice Address - Country:US
Practice Address - Phone:920-921-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4021-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty