Healthcare Provider Details

I. General information

NPI: 1194538074
Provider Name (Legal Business Name): AMANDA REA MILLER RN, MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 IL 162 SUITE 201
MARYVILLE IL
62062
US

IV. Provider business mailing address

6805 IL 162 SUITE 201
MARYVILLE IL
62062
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5019
  • Fax: 618-288-5059
Mailing address:
  • Phone: 618-288-5019
  • Fax: 618-288-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025002297
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2021007992
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209032950
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: