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:PO BOX 39491
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1248
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012888A363LF0000X
MI4704393829363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty