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: | 2753 WISCONSIN ST | ||||||||
| Address2: | |||||||||
| City: | STURTEVANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531771827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628868600 | ||||||||
| FaxNumber: | 2628865342 | ||||||||
| Practice Location | |||||||||
| Address1: | 2753 WISCONSIN ST | ||||||||
| Address2: | |||||||||
| City: | STURTEVANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531771827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628868600 | ||||||||
| FaxNumber: | 2628865342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 111N00000X | 4961-12 | WI | Y | Chiropractic Providers | Chiropractor |
No ID Information.