Provider Demographics
NPI:1164561130
Name:DAVIS, AMY M (APN FNP-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5021
Mailing Address - Country:US
Mailing Address - Phone:309-692-0400
Mailing Address - Fax:309-692-2804
Practice Address - Street 1:2338 W VAN WINKLE WAY STE 3300
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7485
Practice Address - Country:US
Practice Address - Phone:309-693-2020
Practice Address - Fax:309-693-9769
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006059Medicaid
ILQ68423Medicare UPIN