Provider Demographics
NPI:1780326454
Name:BASHAM, AMANDA JUNE (FNP -BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JUNE
Last Name:BASHAM
Suffix:
Gender:F
Credentials:FNP -BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4191
Mailing Address - Country:US
Mailing Address - Phone:618-797-0618
Mailing Address - Fax:
Practice Address - Street 1:3986 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4191
Practice Address - Country:US
Practice Address - Phone:618-797-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025025363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
1811087604OtherNPI