Healthcare Provider Details

I. General information

NPI: 1679437305
Provider Name (Legal Business Name): AMANDA ANNE BREEDING FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ANNE GAVIN

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W MAIN ST
BELLEVILLE IL
62226-6646
US

IV. Provider business mailing address

2801 W MAIN ST
BELLEVILLE IL
62226-6646
US

V. Phone/Fax

Practice location:
  • Phone: 618-416-2018
  • Fax:
Mailing address:
  • Phone: 618-416-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041457427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: