Provider Demographics
NPI:1619742939
Name:FAIRLESS, AMANDA (ADN, RN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FAIRLESS
Suffix:
Gender:F
Credentials:ADN, RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ZAROGOSSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:2311 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62903-5912
Practice Address - Country:US
Practice Address - Phone:618-457-6703
Practice Address - Fax:618-549-3734
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.406811163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse