Provider Demographics
NPI:1144953902
Name:VAN DE WIELLE, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VAN DE WIELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-204-6522
Mailing Address - Fax:
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-204-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1609362375207R00000X
MI4704393829363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty