Provider Demographics
NPI:1346686086
Name:BRANHAM, AMY MICHELLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:BRANHAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 19665
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9665
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7305
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:SUITE PAV 4B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7305
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-010254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid