Provider Demographics
NPI:1922560101
Name:EVERSGERD, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:EVERSGERD
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 1:152 FOREST OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-2847
Mailing Address - Country:US
Mailing Address - Phone:618-531-5802
Mailing Address - Fax:
Practice Address - Street 1:20 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5830
Practice Address - Country:US
Practice Address - Phone:618-531-5802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily