Healthcare Provider Details

I. General information

NPI: 1396681045
Provider Name (Legal Business Name): AMANDA KIMBALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4416 BICKFORD AVE
OSWEGO IL
60543-8158
US

IV. Provider business mailing address

4416 BICKFORD AVE
OSWEGO IL
60543-8158
US

V. Phone/Fax

Practice location:
  • Phone: 630-696-6712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030610
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: