Healthcare Provider Details

I. General information

NPI: 1063756492
Provider Name (Legal Business Name): AMY LYNN STAKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GORE RD
MORRIS IL
60450-9466
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-364-8919
  • Fax:
Mailing address:
  • Phone: 815-941-9124
  • Fax: 815-941-4363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010035
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: