Healthcare Provider Details

I. General information

NPI: 1609118348
Provider Name (Legal Business Name): AMY MANION C.P.N.P., PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY BECKER

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR #123
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

680 N LAKE SHORE DR #123
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-5515
  • Fax: 312-642-0753
Mailing address:
  • Phone: 312-642-5515
  • Fax: 312-642-0753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number209004161
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: