Healthcare Provider Details

I. General information

NPI: 1013533579
Provider Name (Legal Business Name): AMANDA LORIN TAYLOR HAWKINS DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 07/12/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SPRING ST
RED BUD IL
62278-1105
US

IV. Provider business mailing address

325 SPRING ST
RED BUD IL
62278-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-7373
  • Fax:
Mailing address:
  • Phone: 618-282-7373
  • Fax: 618-282-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: