Provider Demographics
NPI:1114745783
Name:ILAG, AMANDA MARIE (AGNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:ILAG
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7805
Mailing Address - Country:US
Mailing Address - Phone:510-929-1400
Mailing Address - Fax:510-929-1414
Practice Address - Street 1:1901 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-1986
Practice Address - Country:US
Practice Address - Phone:510-929-1400
Practice Address - Fax:510-929-1414
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032119363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty