Healthcare Provider Details

I. General information

NPI: 1952849754
Provider Name (Legal Business Name): AMY GILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6307
US

IV. Provider business mailing address

11600 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6307
US

V. Phone/Fax

Practice location:
  • Phone: 708-272-4150
  • Fax:
Mailing address:
  • Phone: 708-272-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015326
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9470249
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: