Provider Demographics
NPI:1629648225
Name:KOSTIC, AMANDA (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KOSTIC
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W ONTARIO ST STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3621
Mailing Address - Country:US
Mailing Address - Phone:312-880-9697
Mailing Address - Fax:
Practice Address - Street 1:222 W ONTARIO ST STE 310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3621
Practice Address - Country:US
Practice Address - Phone:312-880-9697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily