Healthcare Provider Details

I. General information

NPI: 1457361990
Provider Name (Legal Business Name): AMANDA LYNN ANDERSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W LAKE AVE
GLENVIEW IL
60026-1239
US

IV. Provider business mailing address

319 W RIVERSIDE DR
LAKEMOOR IL
60051-8774
US

V. Phone/Fax

Practice location:
  • Phone: 847-486-4627
  • Fax:
Mailing address:
  • Phone: 847-486-4627
  • Fax: 847-486-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.001971
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: