Healthcare Provider Details

I. General information

NPI: 1508388372
Provider Name (Legal Business Name): AMBER LEE-ANN KOTH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-4416
US

IV. Provider business mailing address

221 NE GLEN OAK AVE
PEORIA IL
61636-4416
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5500
  • Fax:
Mailing address:
  • Phone: 309-672-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001734
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: