Healthcare Provider Details

I. General information

NPI: 1871193961
Provider Name (Legal Business Name): AMY PADGETT HEELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15150 US HIGHWAY 150
PARIS IL
61944-6615
US

IV. Provider business mailing address

20059 E 1450TH RD
PARIS IL
61944-8203
US

V. Phone/Fax

Practice location:
  • Phone: 217-466-5818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26018047A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051295182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: