Provider Demographics
NPI:1902855661
Name:CUNNINGHAM, AMY RENAE (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RENAE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEODESHA
Mailing Address - State:KS
Mailing Address - Zip Code:66757-1519
Mailing Address - Country:US
Mailing Address - Phone:620-325-2500
Mailing Address - Fax:620-325-2550
Practice Address - Street 1:2600 OTTAWA RD
Practice Address - Street 2:STE101
Practice Address - City:NEODESHA
Practice Address - State:KS
Practice Address - Zip Code:66757-1897
Practice Address - Country:US
Practice Address - Phone:620-345-2500
Practice Address - Fax:620-325-2550
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0531846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN590085900Medicaid
MNI21924Medicare UPIN
MN080013683Medicare ID - Type Unspecified