Healthcare Provider Details

I. General information

NPI: 1780052027
Provider Name (Legal Business Name): AMIE KRISTINE HERNANDEZ APN/CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST BLDG 7
NORMAL IL
61761-1493
US

IV. Provider business mailing address

1100 BEECH ST BLDG 7
NORMAL IL
61761-1493
US

V. Phone/Fax

Practice location:
  • Phone: 309-361-4974
  • Fax: 309-322-6463
Mailing address:
  • Phone: 309-361-4974
  • Fax: 309-322-6463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number277.001273
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number209013271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: