Provider Demographics
NPI:1942842018
Name:SUBYANTORO, TAMARRA LYNN (APN)
Entity Type:Individual
Prefix:
First Name:TAMARRA
Middle Name:LYNN
Last Name:SUBYANTORO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:TAMARRA
Other - Middle Name:
Other - Last Name:LAMPRECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5114 N GLEN PARK PLACE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4686
Mailing Address - Country:US
Mailing Address - Phone:309-683-5600
Mailing Address - Fax:309-683-5607
Practice Address - Street 1:5114 N GLEN PARK PLACE RD STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-683-5600
Practice Address - Fax:309-683-5607
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner