Healthcare Provider Details

I. General information

NPI: 1891607339
Provider Name (Legal Business Name): AMANDA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 130
ALTON IL
62002-6704
US

IV. Provider business mailing address

1737 REDBIRD CV
SAINT LOUIS MO
63144-1610
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7600
  • Fax:
Mailing address:
  • Phone: 217-720-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2021025542
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: