Provider Demographics
NPI:1770627168
Name:BOBULA, AMY L
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:L
Last Name:BOBULA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:PECKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2837 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6911
Mailing Address - Country:US
Mailing Address - Phone:847-663-1020
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE 18
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4405
Practice Address - Country:US
Practice Address - Phone:847-662-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2073746174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist