Healthcare Provider Details

I. General information

NPI: 1386244713
Provider Name (Legal Business Name): AMANDA KERR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E LINCOLN HWY
NEW LENOX IL
60451-1909
US

IV. Provider business mailing address

501 E LINCOLN HWY
NEW LENOX IL
60451-1909
US

V. Phone/Fax

Practice location:
  • Phone: 815-215-2069
  • Fax:
Mailing address:
  • Phone: 815-215-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.298761
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number051.298761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: