Provider Demographics
NPI:1760017800
Name:MILLER, AMANDA RENEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-7631
Mailing Address - Country:US
Mailing Address - Phone:815-391-1000
Mailing Address - Fax:815-387-7906
Practice Address - Street 1:3815 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-7631
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:815-387-7906
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041430885163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse