Provider Demographics
NPI:1548830573
Name:TILLEMANS, AMANDA MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:TILLEMANS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3540 S BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4907
Mailing Address - Country:US
Mailing Address - Phone:775-247-7624
Mailing Address - Fax:
Practice Address - Street 1:13500 S PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2709
Practice Address - Country:US
Practice Address - Phone:208-336-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID68559363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health