=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376109488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ROSE PLATT FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2019
-----------------------------------------------------
Last Update Date | 05/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 BROADWAY ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62301-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-214-5784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4750 HIGHWAY C
-----------------------------------------------------
City | PALMYRA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63461-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-470-5209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209018939
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------