Provider Demographics
NPI:1215592183
Name:ANDERSON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANDERSON
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 1:22 PARKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:DAHINDA
Mailing Address - State:IL
Mailing Address - Zip Code:61428-9517
Mailing Address - Country:US
Mailing Address - Phone:309-509-3752
Mailing Address - Fax:
Practice Address - Street 1:7717 N ORANGE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9323
Practice Address - Country:US
Practice Address - Phone:309-589-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001779363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner