Healthcare Provider Details

I. General information

NPI: 1689212177
Provider Name (Legal Business Name): AMANDA CHRISTINE MIKLAVCIC DNP PNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2019
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-3026
US

IV. Provider business mailing address

1 ILLINI DR
PEORIA IL
61605-2576
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-2277
  • Fax:
Mailing address:
  • Phone: 309-671-3447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209026119
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.026647
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: