Healthcare Provider Details

I. General information

NPI: 1114569175
Provider Name (Legal Business Name): AMY A HOMERIN APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY A TABB

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax: 309-624-3344
Mailing address:
  • Phone: 309-655-2000
  • Fax: 309-624-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020206
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number209020206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: