Healthcare Provider Details

I. General information

NPI: 1659970267
Provider Name (Legal Business Name): AMANDA SUE KINNE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 N MAIN ST
CANTON IL
61520-1032
US

IV. Provider business mailing address

25788 N VENOVICH RD
CANTON IL
61520-8396
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-8100
  • Fax: 309-647-8580
Mailing address:
  • Phone: 309-221-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051287946
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: