Healthcare Provider Details

I. General information

NPI: 1942842018
Provider Name (Legal Business Name): TAMARRA LYNN SUBYANTORO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMARRA LAMPRECHT

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 N GLEN PARK PLACE RD STE 110
PEORIA IL
61614-4686
US

IV. Provider business mailing address

5114 N GLEN PARK PLACE RD STE 110
PEORIA IL
61614-4686
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-5600
  • Fax: 309-683-5607
Mailing address:
  • Phone: 309-683-5600
  • Fax: 309-683-5607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209019900
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019900
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: