Healthcare Provider Details

I. General information

NPI: 1518438043
Provider Name (Legal Business Name): AMANDA GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 16TH ST
ZION IL
60099-1423
US

IV. Provider business mailing address

224 SARATOGA CT
GURNEE IL
60031-4416
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-8382
  • Fax:
Mailing address:
  • Phone: 224-637-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.008465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: