Healthcare Provider Details

I. General information

NPI: 1619435252
Provider Name (Legal Business Name): AMY LYNN SMITH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2019
Last Update Date: 03/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 WEST ST
PERU IL
61354-2757
US

IV. Provider business mailing address

28 N 42ND RD
MENDOTA IL
61342-9653
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-3300
  • Fax:
Mailing address:
  • Phone: 815-228-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018888
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: