Provider Demographics
NPI:1780052027
Name:HERNANDEZ, AMIE KRISTINE (APN/CNM)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:KRISTINE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:APN/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BEECH ST BLDG 7
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1493
Mailing Address - Country:US
Mailing Address - Phone:309-361-4974
Mailing Address - Fax:309-322-6463
Practice Address - Street 1:1100 BEECH ST BLDG 7
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1493
Practice Address - Country:US
Practice Address - Phone:309-361-4974
Practice Address - Fax:309-322-6463
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013271163WW0101X
IL277.001273367A00000X
IL209.013271367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL15572455901Medicaid