Provider Demographics
NPI:1255168738
Name:SIDES, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SIDES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MOULTRIE COUNTY COUNSELING CENTER
Mailing Address - Street 2:12 W HARRISON STREET
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951
Mailing Address - Country:US
Mailing Address - Phone:217-728-4358
Mailing Address - Fax:217-728-2270
Practice Address - Street 1:MOULTRIE COUNTY COUNSELING CENTER
Practice Address - Street 2:12 W HARRISON STREET
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951
Practice Address - Country:US
Practice Address - Phone:217-728-4358
Practice Address - Fax:217-728-2270
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043114801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse