Provider Demographics
NPI:1467583302
Name:DECIMO, AMANDA M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:M
Last Name:DECIMO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W 22ND ST
Mailing Address - Street 2:#610
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2006
Mailing Address - Country:US
Mailing Address - Phone:630-537-1720
Mailing Address - Fax:
Practice Address - Street 1:1301 W 22ND ST
Practice Address - Street 2:#610
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2006
Practice Address - Country:US
Practice Address - Phone:630-537-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007301367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
G4231OtherBCBSFL
FL308217200Medicaid
FL308217200Medicaid