Provider Demographics
NPI:1477981421
Name:ENDRIZZI, AMANDA (MSPA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ENDRIZZI
Suffix:
Gender:F
Credentials:MSPA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BOLANOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1668
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:618-833-6267
Practice Address - Street 1:803 NORTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995
Practice Address - Country:US
Practice Address - Phone:618-658-2811
Practice Address - Fax:618-658-2439
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004839363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical