Basic Information
Provider Information
NPI: 1003156985
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WHITLEDGE
FirstName: AMANDA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: D.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: NENNEMAN
OtherFirstName: AMANDA
OtherMiddleName: LYNN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 8020 DURAND AVE
Address2: BOX 392
City: STURTEVANT
State: WI
PostalCode: 531771926
CountryCode: US
TelephoneNumber: 2628868600
FaxNumber: 2628865342
Practice Location
Address1: 8020 DURAND AVE
Address2:  
City: STURTEVANT
State: WI
PostalCode: 531771926
CountryCode: US
TelephoneNumber: 2628868600
FaxNumber: 2628865342
Other Information
ProviderEnumerationDate: 02/28/2013
LastUpdateDate: 07/30/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X4961-12WIY Chiropractic ProvidersChiropractor 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


Home