Provider Demographics
NPI:1083096127
Name:BOSE, AMANDA LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LYNN
Last Name:BOSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:PANUSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:721 W LAKE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2035
Mailing Address - Country:US
Mailing Address - Phone:224-730-0113
Mailing Address - Fax:
Practice Address - Street 1:721 W LAKE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2035
Practice Address - Country:US
Practice Address - Phone:224-730-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012737111N00000X
175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No175F00000XOther Service ProvidersNaturopath