Provider Demographics
NPI:1154085504
Name:KILGORE, AMANDA MARIE (APNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:KILGORE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:FAMEREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,APNP
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE STE 501
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-6050
Practice Address - Fax:920-433-6049
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704384074363LF0000X
WI11401-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F08210007OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS