Provider Demographics
NPI:1275027344
Name:MICHAELS, AMANDA WILLANE (ADNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:WILLANE
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:ADNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 E BETHALTO DR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1801
Mailing Address - Country:US
Mailing Address - Phone:618-433-6490
Mailing Address - Fax:
Practice Address - Street 1:163 E BETHALTO DR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-1801
Practice Address - Country:US
Practice Address - Phone:618-433-6490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-017712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily