Provider Demographics
NPI:1912379777
Name:GAWELEK, AMANDA (NP-FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GAWELEK
Suffix:
Gender:F
Credentials:NP-FNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5001 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4799
Mailing Address - Country:US
Mailing Address - Phone:309-693-2225
Mailing Address - Fax:
Practice Address - Street 1:5001 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4799
Practice Address - Country:US
Practice Address - Phone:309-693-2225
Practice Address - Fax:309-693-2228
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013391363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209013391OtherSTATE LICENSE
ILF400271374Medicare PIN