Provider Demographics
NPI:1881030682
Name:ENNEN, AMANDA E (FNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:ENNEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HEALTH CARE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1155
Mailing Address - Country:US
Mailing Address - Phone:618-664-1380
Mailing Address - Fax:618-664-4239
Practice Address - Street 1:201 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1155
Practice Address - Country:US
Practice Address - Phone:618-664-1380
Practice Address - Fax:618-664-4239
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily