Healthcare Provider Details

I. General information

NPI: 1760973424
Provider Name (Legal Business Name): AMELIA L PAULEY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMELIA L MCCLURE PMHNP

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E MACK AVE
OLNEY IL
62450-2319
US

IV. Provider business mailing address

14469 CHAUNCEY RD
SUMNER IL
62466-4306
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-7421
  • Fax:
Mailing address:
  • Phone: 812-891-3410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71008296A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209019285
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28191422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: