Provider Demographics
NPI:1588929186
Name:WONDERLY, AMANDA ADELINE (OD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ADELINE
Last Name:WONDERLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:ADELINE
Other - Last Name:LAPLANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:700 HALE ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-2787
Mailing Address - Country:US
Mailing Address - Phone:800-872-8662
Mailing Address - Fax:608-374-8205
Practice Address - Street 1:700 HALE ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2787
Practice Address - Country:US
Practice Address - Phone:800-872-8662
Practice Address - Fax:608-374-8205
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA1573002Medicare UPIN
12585049OtherCAQH
KSKA1573002OtherMEDICARE PTAN