Healthcare Provider Details

I. General information

NPI: 1376829010
Provider Name (Legal Business Name): AMANDA MARIE ALLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE CRAWFORD

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 N STATE ROUTE 91 SUITE 300
PEORIA IL
61615-9541
US

IV. Provider business mailing address

2401 W ALTA RD APT. 1904
PEORIA IL
61615-1279
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-6616
  • Fax: 309-691-2943
Mailing address:
  • Phone: 219-508-5791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004220
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: