MEDICARE: AMBER NICOLE KINGERY MASTERS PTA

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	225200000X	Physical Therapy Assistant		IL

General Provider Information

NPI Number	:	1720367063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER NICOLE KINGERY MASTERS PTA

Provider Business Mailing Address
First Line	:	6501 N SHERIDAN RD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-2932
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 N BOURLAND AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61606-1214
Country	:	US
Telephone Number	:	309-258-2040
Fax Number	:

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

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	08/04/2011

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