Healthcare Provider Details

I. General information

NPI: 1316398415
Provider Name (Legal Business Name): AMANDA JOY KILZER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S CENTER ST
MARYVILLE IL
62062-5401
US

IV. Provider business mailing address

2401 S CENTER ST
MARYVILLE IL
62062-5401
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-3046
  • Fax: 618-344-5284
Mailing address:
  • Phone: 618-344-3046
  • Fax: 618-344-5284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: