Provider Demographics
NPI:1659970267
Name:KINNE, AMANDA SUE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:KINNE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25788 N VENOVICH RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-8396
Mailing Address - Country:US
Mailing Address - Phone:309-221-1094
Mailing Address - Fax:
Practice Address - Street 1:2071 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-1032
Practice Address - Country:US
Practice Address - Phone:309-647-8100
Practice Address - Fax:309-647-8580
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 225XE1200X
IL051287946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics