MEDICARE: MRS. AMANDA LYNN ANDERSON ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096.001971	IL

General Provider Information

NPI Number	:	1457361990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA LYNN ANDERSON ATC

Provider Business Mailing Address
First Line	:	319 W RIVERSIDE DR
Second Line	:
City	:	LAKEMOOR
State	:	IL
Zip	:	60051-8774
Country	:	US
Telephone Number	:	847-486-4627
Fax Number	:	847-486-5702

Provider Business Practice Location Address
First Line	:	4000 W LAKE AVE
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-1239
Country	:	US
Telephone Number	:	847-486-4627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	12/07/2011

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