Provider Demographics
NPI:1164561130
Name:DAVIS, AMY MARIE (APN FNP-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-0400
Mailing Address - Fax:309-692-2804
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 207
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5021
Practice Address - Country:US
Practice Address - Phone:309-692-0400
Practice Address - Fax:309-692-2804
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006059363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006059Medicaid
ILQ68423Medicare UPIN