Provider Demographics
NPI: | 1245787373 |
---|---|
Name: | PERROT, AMANDA CHRISTINE (APN) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | AMANDA |
Middle Name: | CHRISTINE |
Last Name: | PERROT |
Suffix: | |
Gender: | F |
Credentials: | APN |
Other - Prefix: | MRS |
Other - First Name: | AMANDA |
Other - Middle Name: | CHRISTINE |
Other - Last Name: | STEINBERG |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 680 N LAKE SHORE DR STE 1000 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60611-8709 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 312-695-0665 |
Mailing Address - Fax: | 630-499-2399 |
Practice Address - Street 1: | 235 S GARY AVE STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | BLOOMINGDALE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60108-2213 |
Practice Address - Country: | US |
Practice Address - Phone: | 630-893-9600 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-09-07 |
Last Update Date: | 2019-09-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 209014715 | 163W00000X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 209014715 | Medicaid |