Provider Demographics
NPI:1356695043
Name:LEE, AMANDA M (MSN, PNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:LEE
Suffix:
Gender:F
Credentials:MSN, PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 S LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3018
Mailing Address - Country:US
Mailing Address - Phone:312-666-6511
Mailing Address - Fax:312-666-1658
Practice Address - Street 1:1817 S LOOMIS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3018
Practice Address - Country:US
Practice Address - Phone:312-666-6511
Practice Address - Fax:312-666-1658
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009815363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics