Provider Demographics
NPI:1861702532
Name:KRUTKE, AMANDA K (ACNS-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:KRUTKE
Suffix:
Gender:F
Credentials:ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W NORTH ST
Mailing Address - Street 2:STE 206207
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8201
Mailing Address - Country:US
Mailing Address - Phone:815-478-7866
Mailing Address - Fax:
Practice Address - Street 1:107 OMNI DR
Practice Address - Street 2:SUITE A
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-885-7886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18259364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2010002179OtherACNS-BC CERTIFICATION