MEDICARE: AMANDA CHRISTINE MIKLAVCIC DNP PNP-AC

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	363L00000X	Nurse Practitioner	APRN.CNP.026647	OH
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363LP0200X	Pediatric Nurse Practitioner	209026119	IL

General Provider Information

NPI Number	:	1689212177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA CHRISTINE MIKLAVCIC DNP PNP-AC

Provider Business Mailing Address
First Line	:	1 ILLINI DR
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61605-2576
Country	:	US
Telephone Number	:	309-671-3447
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 NE GLEN OAK AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61637-3026
Country	:	US
Telephone Number	:	309-624-2277
Fax Number	:

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

Provider Enumeration Date	:	12/15/2019
Last Update Date	:	01/31/2024

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