Provider Demographics
NPI:1386180362
Name:GUMIENY, AMY SUE (NP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:GUMIENY
Suffix:
Gender:F
Credentials:NP
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:700 PARK RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7526363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100064831Medicaid