Provider Demographics
NPI:1730852807
Name:VIDNOVIC, AMY WOLFF (CPNP-PC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:WOLFF
Last Name:VIDNOVIC
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:WOLFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4664
Mailing Address - Country:US
Mailing Address - Phone:914-960-9935
Mailing Address - Fax:
Practice Address - Street 1:7 ALFRED ST STE 220
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1939
Practice Address - Country:US
Practice Address - Phone:781-933-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics