Provider Demographics
NPI:1659519247
Name:COCKRELL- TAPALLA, AMANDA L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:COCKRELL- TAPALLA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W JACKSON BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3276
Mailing Address - Country:US
Mailing Address - Phone:312-942-8000
Mailing Address - Fax:312-942-3551
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:312-942-8000
Practice Address - Fax:312-942-3551
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007435363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily