Healthcare Provider Details

I. General information

NPI: 1639492655
Provider Name (Legal Business Name): AMY KATHLEEN ULRICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY KATHLEEN GUY

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7309 N KNOXVILLE AVE
PEORIA IL
61614-2085
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number082688
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209008371
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: